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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 kills and experience that directly relate to this position. 

Job Summary

  • To assist in the development, coordination and implementation of activities to assure compliance with accreditation and regulatory requirements
  • Provide in-depth understanding of current practices in Michigan Medicine.
  • Support clinical compliance with the TJC, State & Federal regulations. 
  • Implement and assist in the evaluation of on-going compliance with accrediting & regulatory standards.
  • Participate in accreditation & regulatory survey visits
  • Assist in preparing status reports, proposals and presentations as assigned

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 26,000 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.


  • Provide direction and oversight for regulatory and accreditation compliance including TJC, State and Federal agencies. 
  • Coordinate designated efforts to assure compliance with accreditation and regulatory requirements including
    • developing systems to ensure continual organizational readiness;
    • gathering, synthesizing, and analyzing data from departments;
    • providing consultation to departments around compliance initiatives;
    • Monitoring the progress of corrective action plans/improvement projects. 
  • Remain current with accreditation and regulatory standards. 
  • Audit and provide feedback on regulatory compliance
  • Function as a resource and educator to support the management team and staff of the organization on accreditation plans to assure compliance.
  • Develop and implement annual Continuous Readiness Plan to achieve compliance with accreditation and regulatory standards. 
  • Participate in accreditation and regulatory visits. 
  • Monitor adherence to institutional programs and materials related to accreditation and regulatory requirements. 
  • Coordinate and communicate educational offerings related to accreditation and regulatory requirements across the organization. 
  • Assist in preparing status reports, proposals and presentations as assigned.
  • Maintain collaborative relationships between impacted departments, units, hospitals/healthcare centers and appropriate regulatory agencies.
  • Able to perform a wide range of physical activities: prolonged sitting/standing/walking, lifting, pulling, bending and manual dexterity movements.
  • Other duties as applicable.

Required Qualifications*

  • Minimally 5 years’ clinical experience.
  • Bachelor’s degree in a related field such as Nursing or Quality or a combination of education & experience in accreditation is required. 
  • Additional educational training in Joint Commission accreditation standards is required.  
  • Master’s degree in a health care field or quality preferred.  Current State of Michigan Board of Nursing licensure is required, if applicable. 
  • Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and/or teams, across disciplines, is essential. 
  • Proven organizational skills. 
  • Experience in teaching, training, and policy/procedure development
  • Excellent communication skills, as demonstrated in oral, written and presentation forms is necessary.
  • Demonstrated ability to work independently, to meet deadlines efficiently, to perform multiple tasks simultaneously and to be highly self-motivate
  • Previous accreditation/regulatory readiness experience preferred
  • CJCP preferred

Physical Requirements:

The employee will be able to perform the assigned duties and responsibilities with or without reasonable accommodations: ability to walk for long periods of time, ability to communicate/ exchange information, fine motor coordination/dexterity necessary for keyboarding or typing, and may require reaching, bending, twisting, stooping, moving about, lifting of up to 10 pounds, etc., with or without the use of assistive/adaptive devices.

Desired Qualifications*

  • Masters degree in a healthcare field or quality preferred
  • Current State of Michigan Board of Nursing licensure if applicable
  • Ability to use web publishing tools is desired
  • Certified as a Joint Commission Professional CJCP

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.

U-M EEO/AA Statement

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