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Job Summary

This posting will fill 2 openings.

  • 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 UMHS
  • Support clinical compliance with the TJC, State and Federal regulations
  • Implement and assist in the evaluation of ongoing compliance with accrediting and regulatory standards
  • Participate in accreditation and 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.


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. 
Other duties as applicable.

Required Qualifications*

  • Bachelor’s degree in Nursing, other health care field, or quality is required. 
  • Additional educational training in Joint Commission accreditation standards is required.  
  • Demonstrated knowledge of process improvement and outcome measurement is essential. 
  • Knowledge of quality improvement tools. 
  • Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and/or teams, across disciplines, is essential. 
  • Demonstrated skills and competence in accreditation and regulatory compliance. 
  • Proven organizational skills. 
  • Excellent communication skills, as demonstrated in oral, written and presentation forms is necessary.

Desired Qualifications*

  • Masters degree in a health care 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 Join 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.

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.