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.
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
Provides coordination and oversight for regulatory and accreditation compliance including the Joint Commission, State and Federal agencies
Remains current with accreditation and regulatory standards.
Conducts mock surveys/tracers to assess state of readiness of MM and gather information about performance.
Coordinates designated efforts to implement and evaluate 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.
Partners with colleagues in nursing quality, risk, patient safety and operations to identify areas for opportunity and improvements.
Participate in accreditation & regulatory survey visits
Provides in-depth understanding of current regulatory practices in Michigan Medicine.
Functions as a resource and educator to support the management team and staff of the organization on accreditation plans to assure compliance.
Coordinates and communicates educational offerings related to accreditation and regulatory requirements across the organization.
Maintains collaborative relationships between impacted departments, units, hospitals/healthcare centers and appropriate regulatory agencies.
Assists in preparing status reports, proposals and presentations as assigned
Is knowledgeable about regulatory standards, can evaluate performance against those standards, and can effectively communicate and lead change to meet standards.
Provides a single point of contact and oversees multiple complex projects within the organization to assure compliance with the Joint Commission, State and Federal agencies.
Acts as a coordinator for activities of multiple project managers, assigns and coordinates resources to facilitates change based on requirements of regulatory standards and monitor’s progress.
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 project accordingly.
Other duties as applicable.
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
Current State of Michigan Board of Nursing licensure is required, if applicable.