Quality/Accreditation Specialist II
General Summary:
Under limited direction, the Quality/Accreditation Specialist II plans, organizes, and maintains processes to ensure organizational compliance with regulatory standards and continuous survey readiness. This role serves as an internal consultant for interpreting standards and measuring functional compliance across departments. The specialist develops performance improvement plans with management and staff as needed, interprets new regulations for educational purposes, and drives implementation efforts. The role requires the ability to work independently, manage multiple priorities, and provide expert guidance on accreditation and regulatory requirements.
Principal Duties and Responsibilities:
Plans, organizes, and manages systems to ensure compliance with accreditation and regulatory requirements (TJC, DNV, CMS Conditions of Participation, and others).
Serves as a resource and internal consultant for interpretation of regulatory standards and evaluation of compliance across departments.
Partners with management and staff to develop and implement performance improvement plans to address gaps identified during audits or reviews.
Interprets new or updated regulations, providing education and training to leadership and staff to ensure understanding and compliance.
Facilitates and participates in quality improvement (QI) and performance improvement (PI) initiatives as a team member, lead, or facilitator (1–3 years of prior QI/PI experience required).
Collaborates with multidisciplinary teams, leadership, and service lines to drive continuous survey readiness and regulatory excellence.
Prepares and delivers presentations to departmental, product line, and business unit leadership regarding compliance, survey readiness, and quality initiatives.
Monitors trends and current issues in healthcare to ensure ongoing alignment with best practices and regulatory requirements.
Maintains flexibility to be onsite during unannounced regulatory surveys and provides hands-on support during survey activities.
Travels to multiple organizational locations as required to support survey preparation and compliance monitoring.
Education and Experience Requirements:
Bachelor’s degree in Nursing or healthcare-related field required.
Master’s degree in healthcare field preferred.
Registered Nurse (RN) preferred.
Minimum 5 years of hospital experience required; clinical or operational experience preferred.
Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required; familiarity with other accrediting, licensing, and regulatory standards preferred.
Evidence of continuing education in standards, regulations, and compliance training required.
QI/PI team member, lead, or facilitator experience (1–3 years required).
Experience working across multiple departments or deep expertise within a single service line or value stream.
Experience presenting to leadership groups and working with broad business unit teams.
Knowledge of current healthcare issues and trends required.
Accreditation experience preferred.
Skills and Abilities:
Ability to work independently, prioritize tasks, and manage multiple projects in a fast-paced environment.
Strong analytical and problem-solving skills to evaluate compliance and develop actionable solutions.
Exceptional communication and presentation skills, with the ability to educate and influence at all organizational levels.
Flexibility to support unannounced regulatory surveys and rapidly changing priorities.
Proficiency with healthcare regulations, standards, and survey readiness processes.
Willingness and ability to travel to multiple sites as needed.
Work Environment:
Hybrid position – combination of onsite and remote work, with required availability to be onsite during regulatory surveys or as organizational needs dictate.
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.
