Quality/Accreditation Spec II- Medical Affairs - 40 Hours - Days Eligible for Full-Time Benefits Shift: Midnights 7:30 am to 4:30 pm, no weekends. GENERAL SUMMARY: Under limited direction, plans, organizes and maintains a process to ensure organizational compliance with regulatory standards and continuous survey readiness. Serves as an internal consultant for the interpretation of standards and functional measurement of compliance. Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts. PRINCIPAL DUTIES AND RESPONSIBILITIES:
In collaboration with corporate and business unit leadership: Provides direction and oversight to regulations/accreditation compliance including but not limited to: TJC, DNV, State and Federal agencies (CMS) for hospital/system. Develops and monitors the org. infrastructure necessary to assure ongoing compliance with standards/regulations. Functions as a consultant, resource, educator to support the leadership team. - Develops/implements an ongoing readiness plan to achieve continuous readiness/compliance Reviews and/or develops Policies/Procedures assuring compliance with regs. Manages associates and activities to ensure continuous operation and delivery of services Serves as a technical resource and assists in resolution of complex problems when necessary. Coordinates agency specific accreditation requirements (TJC/DNV) - Assists depts. in resolution of deficiencies by providing strategies that successfully meet the intent of the standards. Provides leadership/direction for on-site surveys and unannounced visits Provides routine reports to the quality committee; other committees regarding problem-prone areas, action plans, etc. Continuous learner regarding accreditation standards, Fed, state, local laws, regulations, compliance program, code of conduct as well as other p/p's in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
EDUCATION/EXPERIENCE REQUIRED:
Bachelor's degree in nursing or healthcare related field required, master's degree in health care field preferred; RN preferred Minimum 5 years hospital experience required; clinical/operational experience preferred Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable. - Evidence of continuing education in standards/regulations/training
- Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable.
- QI/PI Team member, lead or facilitator 1 - 3 years required Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and//or "deep" experience within one service line, value stream, etc.
- Experience presenting to departmental, product line, and business unit leadership
Knowledge of current healthcare issues and trend Additional Information
- Organization: Henry Ford Macomb - Oakland Hospitals
- Department: Medical Affairs Admin 001
- Shift: Day Job
- Union Code: Not Applicable
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Henry Ford Health System
Dec 04, 2025