Quality/Accreditation Specialist II General Summary: Under limited direction, the Quality/Accreditation Specialist II plans, organizes, and maintains processes to ensure organizational compliance with regulatory standards and continuous survey readiness. This role serves as an internal consultant for interpreting standards and measuring functional compliance across departments. The specialist develops performance improvement plans with management and staff as needed, interprets new regulations for educational purposes, and drives implementation efforts. The role requires the ability to work independently, manage multiple priorities, and provide expert guidance on accreditation and regulatory requirements.
Principal Duties and Responsibilities:
Plans, organizes, and manages systems to ensure compliance with accreditation and regulatory requirements (TJC, DNV, CMS Conditions of Participation, and others).
Serves as a resource and internal consultant for interpretation of regulatory standards and evaluation of compliance across departments.
Partners with management and staff to develop and implement performance improvement plans to address gaps identified during audits or reviews.
Interprets new or updated regulations, providing education and training to leadership and staff to ensure understanding and compliance.
Facilitates and participates in quality improvement (QI) and performance improvement (PI) initiatives as a team member, lead, or facilitator (1-3 years of prior QI/PI experience required).
Collaborates with multidisciplinary teams, leadership, and service lines to drive continuous survey readiness and regulatory excellence.
Prepares and delivers presentations to departmental, product line, and business unit leadership regarding compliance, survey readiness, and quality initiatives.
Monitors trends and current issues in healthcare to ensure ongoing alignment with best practices and regulatory requirements.
Maintains flexibility to be onsite during unannounced regulatory surveys and provides hands-on support during survey activities.
Travels to multiple organizational locations as required to support survey preparation and compliance monitoring.
Education and Experience Requirements:
Bachelor's degree in Nursing or healthcare-related field required.
Master's degree in healthcare field preferred.
Registered Nurse (RN) preferred.
Minimum 5 years of hospital experience required; clinical or operational experience preferred.
Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required; familiarity with other accrediting, licensing, and regulatory standards preferred.
Evidence of continuing education in standards, regulations, and compliance training required.
QI/PI team member, lead, or facilitator experience (1-3 years required).
Experience working across multiple departments or deep expertise within a single service line or value stream.
Experience presenting to leadership groups and working with broad business unit teams.
Knowledge of current healthcare issues and trends required.
Accreditation experience preferred.
Skills and Abilities:
Ability to work independently, prioritize tasks, and manage multiple projects in a fast-paced environment.
Strong analytical and problem-solving skills to evaluate compliance and develop actionable solutions.
Exceptional communication and presentation skills, with the ability to educate and influence at all organizational levels.
Flexibility to support unannounced regulatory surveys and rapidly changing priorities.
Proficiency with healthcare regulations, standards, and survey readiness processes.
Willingness and ability to travel to multiple sites as needed.
Work Environment:
Additional Information
- Organization: Corporate Services
- Department: Ambulatory Nursing and Quality
- Shift: Day Job
- Union Code: Not Applicable
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Henry Ford Health System
remote work
Jul 22, 2025