Quality/Accreditation Spec II - Ambulatory Nursing - Detroit

Quality/Accreditation Specialist II

GENERAL SUMMARY

Under limited direction, the Quality/Accreditation Specialist II supports organizational compliance with regulatory, accreditation, and licensing standards and promotes continuous survey readiness. Serves as an internal consultant for standards interpretation, compliance assessment, education, and performance improvement. Partners with leaders and multidisciplinary teams to identify gaps, develop improvement plans, and implement regulatory requirements.

KEY RESPONSIBILITIES

• Maintains processes to support regulatory and accreditation compliance and continuous survey readiness.
• Interprets and communicates TJC, DNV, CMS Conditions of Participation, and other applicable standards and regulations.
• Monitors regulatory changes and supports education and implementation efforts.
• Conducts compliance reviews, audits, tracers, and assessments to identify gaps and improvement opportunities.
• Collaborates with leaders and staff to develop and implement performance improvement plans.
• Facilitates quality and performance improvement initiatives and monitors outcomes.
• Provides education and consultation related to accreditation, regulatory compliance, quality, and survey readiness.
• Supports accreditation and regulatory surveys, including unannounced surveys requiring onsite presence.
• Presents compliance findings, trends, and recommendations to departmental, product line, and business unit leadership.
• Maintains knowledge of current healthcare regulations, quality practices, and industry trends.

EDUCATION AND EXPERIENCE REQUIRED

• Bachelor's degree in Nursing, Healthcare, or related field required; Master's degree preferred.
• RN or clinical experience preferred.
• Minimum five (5) years of hospital experience required; clinical or operational experience preferred.
• One (1) to three (3) years of Quality/Performance Improvement team, lead, or facilitator experience required.
• Knowledge of TJC, DNV, and CMS Conditions of Participation required.
• Accreditation, regulatory, and quality experience preferred.
• Continuing education in standards, regulations, quality improvement, or performance improvement preferred.

SKILLS AND ABILITIES

• Strong knowledge of healthcare regulatory, accreditation, and quality standards.
• Strong analytical, organizational, communication, and presentation skills.
• Ability to interpret complex standards and translate requirements into actionable processes.
• Experience working with multidisciplinary teams and presenting to leadership.
• Ability to manage multiple priorities and work independently with limited direction.
• Knowledge of current healthcare issues and trends.

WORKING CONDITIONS

• Requires travel between multiple sites.
• Must be readily available for onsite support during unannounced surveys with minimal notice.
• Schedule flexibility may be required based on organizational and survey needs.

Additional Information

• Organization: Corporate Services
• Department: Ambulatory Nursing and Quality
• Shift: Day Job
• Union Code: Not Applicable