Process Improvement & Accreditation Specialist

Sioux Center Health; Sioux Falls (SD); On-site; USD 65,000 - 90,000; Full time

Job summary

Avera Heart Hospital in Sioux Falls, SD is seeking a Process Improvement & Accreditation Specialist to drive continuous survey readiness by managing regulatory compliance, conducting tracers, and ensuring adherence to TJC and CMS standards.

The role supports organization-wide performance improvement and peer-review activities in line with PI Plan, Medical Staff bylaws, rules and FPPE/OPPE policies, with a Monday–Friday schedule and occasional weekends.

Qualifications

• Associate degree required; bachelor’s degree preferred.
• Licensed as a registered nurse or healthcare professional.
• Experience with regulatory compliance and accreditation programs.

Responsibilities

• Drive survey readiness by managing regulatory compliance.
• Conduct tracers and ensure adherence to TJC and CMS standards.
• Support organization-wide performance improvement and peer-review activities.

Skills

Regulatory compliance

Performance improvement

Data analysis

Tracers

CMS standards

Education

Associate degree in health information administration

Bachelor's degree preferred

Job description

Location:

Sioux Falls, SD

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

At Avera Heart Hospital, you’re not just joining a workplace – you’re becoming part of a family. With more than 700 dedicated employee, we deliver care that truly makes a difference. Our commitment to excellence has earned us the distinction of being one of only a handful of hospitals nationwide – out of more than 4,000 – to achieve a double 5-star rating from the Centers for Medicare and Medicaid Services.

Position Highlights

Position Summary:

The Process Improvement & Accreditation Specialist drives continuous survey readiness by managing regulatory compliance, conducting tracers, and ensuring adherence to TJC and CMS standards. This position is responsible for supporting systematic organization-wide performance improvement, the medical staff peer review activities on quality of care and comparative data and focus studies in accordance with the PI Plan, Medical Staff Bylaws, Rules and Regulations and the OPPE/FPPE policy and procedure.

Work Schedule:

Monday through Friday and occasional weekends depending on the needs of the hospital

Education/Experience:

Associate’s degree in health information administration, healthcare administration, business, nursing or respiratory required, bachelor’s degree preferred.

Licensure/Certification:

Licensed as a registered nurse or healthcare professional required,