Accreditation and Regulatory Program Leader

Trinity Health MI; Livonia (MI); On-site; USD 95,000 - 130,000; Full time

Benefits offered by this job

Competitive compensation

DAILY PAY

Benefits from Day One

Full benefits package (medical, dental

vision, PTO, life insurance, STD/LTD

Employer retirement match and 401k

Growth and advancement

Tuition Reimbursement

Job summary

Trinity Health Livonia invites an experienced Accreditation & Regulatory Program Leader to join the Quality Performance Improvement team. This role directs external regulatory compliance, patient safety standards, and survey readiness across inpatient and outpatient services, collaborating with local and regional leaders to align clinical processes with accreditation requirements.

The ideal candidate holds a bachelor’s in nursing, pharmacy, or a health-care field, a master’s degree preferred,

Qualifications

• Bachelor’s degree in nursing, pharmacy or health care systems; Master’s degree preferred.
• Five years of clinical experience with 1–2 years in leadership or management.
• Accreditation experience with understanding of regulatory requirements and health care operations; CJCP preferred.

Responsibilities

• Manage and direct implementation of organization regulatory compliance activities across all areas.
• Lead organization in pre-survey activities.
• Coordinate responses during CMS, state licensing, and Joint Commission surveys.
• Communicate survey results and develop action plans within regulatory timelines.
• Manage complaint responses and action plans.
• Oversee accreditation software and related portals for compliance reporting.
• Apply performance improvement methodologies to address compliance gaps.
• Collaborate with leadership to respond to new regulations and standards.

Skills

Leadership

Regulatory knowledge

Communication

Analytical skills

Education

Bachelor’s degree in nursing, pharmacy or health care systems

Master’s degree in healthcare or healthcare-related field

Six Sigma Green Belt or higher

Tools

Accreditation software

Joint Commission Extranet

CMS.gov resources

Job description

Description

Accreditation & Regulatory Program Leader

Employment Type

Full time

Shift

Day Shift

Department

Quality Performance Improvement

Location

Trinity Health Livonia

Total Rewards and Benefits

• Competitive compensation, DAILYPAY
• Benefits effective Day One! No waiting periods.
• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability
• Retirement savings plan with employer match and contributions
• Opportunity for growth and advancement throughout Trinity Health
• Tuition Reimbursement

Position Purpose

Provides management and expertise in the areas of external regulatory compliance, and quality and patient safety standards as it relates to colleagues, medical staff, and inpatient/outpatient services. Collaborates with local and regional leadership to direct and coordinate the planning, implementation and evaluation of clinical process related to regulatory compliance. Leverages clinical information technology, process design, change management and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards.

Shifts Available

Days

Status Available

Full-time, 40 hours/week

Required Qualifications

Education

Bachelor's degree in nursing, pharmacy or other clinical or health care systems background. Master's degree in healthcare or healthcare-related field and Six Signma training at green belt or higher is preferred.

Experience

A minimum of five years clinical experience, including at least one to two years in leadership or management. Experience with and understanding of key functions of hospital and medical staff departments or services. Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred. Certificate as a Joint Commission Professional (CJCP) preferred.

Physical and Mental Requirements and Working Conditions

• Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals.
• Advanced analytical and computer skills in order to manage project work and data.
• Advanced critical thinking skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems, policies and procedures, evaluating clinical practice outcomes and developing educational programs.

What you will do

• Manages and directs the implementation of organization regulatory compliance activities across all areas, partnering with unit and program managers and leaders as appropriate.
• Leads the organization in pre-survey activities.
• Coordinates organizational response during CMS, state licensing surveys and Joint Commission surveys.
• Communicates survey results, develops action plans and survey responses in accordance with regulatory timelines.
• Manages complaint responses and associated action plans.
• Manages the routine and ongoing function of the accreditation software, Joint Communication extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements.
• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.
• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.