Accreditation and Regulatory Coordinator

A cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.

Job Summary

This position will report directly to the Director of Accreditation & Regulatory Readiness. This leadership position requires the individual to be knowledgeable about the Joint Commission Standards and CMS Conditions of Participation and remain current. Based on this knowledge, the person can evaluate and provide an in-depth understanding of current regulatory practices at Michigan Medicine by coordinating and leading accreditation and regulatory readiness surveys and assessing compliance with The Joint Commission and State and Federal agencies standards. The individual in this role must be a proven leader with good communication and problem-solving skills and an ability to work independently and lead change. Under FLSA, incumbents in this position meet the criteria for exempt status.

NOTE: Required qualifications must be met by the candidate in order to be interviewed and considered for the position

RESUME REQUIRED (for both internal & external applicants):

You must attach a complete and accurate resume to be fully considered for this position.

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Why Join Michigan Medicine?

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine is comprised of over 30,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems. In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

What Benefits can you Look Forward to?

• Excellent medical, dental and vision coverage effective on your very first day
• 2:1 Match on retirement savings

Responsibilities*

50% – Conduct mock surveys/tracers to assess MM’s state of readiness and gather information about performance.

10% – Participate in accreditation & regulatory survey visits, including CMS complaint visits and TJC triennial and complaint surveys.

15% – Coordinates designated efforts to implement and evaluate compliance with accreditation and regulatory requirements, including:

• Develop systems to ensure continual organizational readiness.
• Gathering, synthesizing, and analyzing data from departments.
• Partner with Chapter leads to assess compliance with TJC Standards and CMS CoPs and identifies opportunities for improvement for non-compliance.

20% – Acts as a coordinator for activities of multiple complex projects, assigns and coordinates resources to ensure compliance and facilitate change based on requirements of regulatory standards and monitor progress.

• Providing consultation to departments around compliance initiatives.
• Partners with colleagues in nursing quality, risk, patient safety, and operations to identify opportunities for improvement.
• Monitoring the progress of corrective action plans/improvement projects.
• Functions as a resource and educator to support the management team and staff of the organization on accreditation plans to assure compliance.
• Develops project plans and facilitates resolution of all issues to reach project goals based on the risk to the organization with regulatory bodies. Defines priorities and drives projects accordingly.
• Maintains collaborative relationships between impacted departments, units, hospitals/healthcare centers, and appropriate regulatory agencies.

5% – Assists in preparing status reports, proposals and presentations as assigned.

• Coordinates and communicates educational offerings related to accreditation and regulatory requirements across the organization.
• Other duties as applicable.

Required Qualifications*

• Bachelor’s degree in a related field such as Nursing or Quality or heath care related field or a combination of education & experience in accreditation is required.
• Minimally 5 years’ clinical experience.
• Demonstrated knowledge of, and experience with, the Continuous Quality Improvement process.
• Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and/or teams, across disciplines, is essential.
• Ability to function independently and as a team member is required.
• Proven organizational skills.
• Experience in teaching, training, and policy/procedure development
• Excellent communication skills, as demonstrated in oral, written and presentation forms is necessary.
• High level of self-motivation to stay current in a rapidly changing environment is required.
• Competence with basic computer software (e.g. Microsoft Word, Microsoft Excel, etc.) is required

Desired Qualifications*

• Previous accreditation/regulatory readiness experience preferred
• Master’s degree in Nursing, Quality or a health care related field
• Ability to use web publishing tools desired

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the .

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.

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