Process Improvement & Accreditation Specialist

Avera Heart Hospital, South Dakota; Sioux Falls (SD); On-site; USD 70,000 - 100,000; Full time

Job summary

Avera Heart Hospital in Sioux Falls, SD is seeking a Process Improvement & Accreditation Specialist to lead regulatory compliance and performance improvement initiatives. The role focuses on tracers, adherence to TJC and CMS standards, and supporting organization-wide quality activities.

The ideal candidate holds an associate degree in a health-related field, is licensed as a nurse or healthcare professional, and bachelor’s degree is preferred to advance initiative and governance across hospital

Qualifications

• Associate degree required in health information admin, healthcare admin, business, nursing or respiratory.
• Licensed as a registered nurse or healthcare professional.
• Bachelor’s degree preferred.

Responsibilities

• Drive continuous 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.
• Align with PI Plan, Medical Staff Bylaws, Rules and Regulations and OPPE/FPPE policy.

Skills

Regulatory compliance

Quality improvement

Data tracing

PI knowledge

Education

Associate degree in health information administration

Bachelor’s degree preferred

Job description

Location:Sioux Falls, SDWorker Type:RegularWork 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 HighlightsPosition 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 hospitalEducation/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,