Accreditation and Regulatory Coordinator

How to Apply

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.

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.

Job Summary

This position will report directly to the Director of Accreditation & Regulatory Readiness. The person in this role will have a wide variety of responsibilities but will be primarily responsible for coordinating and leading accreditation and regulatory readiness surveys for Michigan Medicine. This is a leadership position that requires the individual to be knowledgeable about the Joint Commission Standards and CMS Conditions of Participation. The individual in this role must be a proven leader with good communication and problem-solving skills with an ability to work independently. Under FLSA, incumbents in this position meet the criteria for exempt status.

Responsibilities*

40% - Survey Readiness Activities

• Reviews and analyzes historical data from mock, actual surveys

• Internal audit tool development

• Scheduling/coordinating mock surveys

• Collaborates with leadership to develop action plans

• Monitoring ongoing compliance data with leadership

• Supporting consultant visits, including intracycle monitoring

• Developing reports in the electronic health record

• Facilitating chapter scoring

• Ongoing auditing platform maintenance

• Develops and provides education to employees, leadership, and the medical staff

• Involved with policy development and review

• Engaged in work groups or special projects (i.e., new construction, licensure changes, accreditation standard updates)

20% - Ongoing Education

• Reviews publications from Joint Commission, CMS, LARA and others as applicable

• Attends meetings/conferences with collaboratives and/or consultant services

• Obtaining and maintaining job-related certifications, as applicable

30% - Survey Facilitation Activities

• Facilitating/coordinating actual surveys by accrediting organizations, and visits from State and Federal agencies

• Collaborating with leadership to develop action plans

• Monitoring ongoing compliance data with leadership

10% - Other duties as assigned

Required Qualifications*

• Ability to reliably attend virtual meetings.

• Bachelor's degree in a related field such as Nursing or Quality or health care related field or a combination of education & experience in accreditation. 

• 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, teams, and across disciplines, is essential.

• Ability to function independently and as a team member. 

• Proven organizational skills. 

• Experience in teaching, training, and policy/procedure development

• Excellent communication skills, as demonstrated in oral, written and presentation forms as necessary.

• High level of self-motivation to stay current in a rapidly changing environment.

• Competence with basic computer software (e.g., Microsoft Office applications).

Desired Qualifications*

• Previous accreditation/regulatory readiness experience preferred
• Master's degree in Nursing, Quality or a health care related field 
• Current State of Michigan Board of Nursing licensure 

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

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 work modes.

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 Statement

The University of Michigan is an Equal Opportunity Employer. We are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants, including protected veterans and individuals with disabilities.