Accreditation and Performance Improvement Specialist

* Area of Interest: Business Professionals * FTE/Hours per pay period: 1.0 * Department: Quality Improvement * Shift: Monday-Friday; 8:00am-4:30pm; no weekends or holidays * Job ID: 182356 Overview Shift: Monday-Friday; 8:00 AM - 4:30 PM (no weekends or holidays) Help lead the charge in keeping our hospital at the highest standards of excellence! In this role, you'll play a key part in maintaining hospital accreditation by ensuring compliance with Centers for Medicare & Medicaid Services (CMS) requirements. You'll partner with leaders across the organization to guide best practices, interpret CMS Conditions of Participation for Acute Care Hospitals, and drive continuous improvement initiatives. If you enjoy problem-solving, collaborating with teams, and making a meaningful impact on patient care and operational excellence, this is an opportunity to make a real difference every day. Ready to turn standards into success and make an impact behind the scenes of exceptional patient care? Apply today and help us raise the bar in healthcare excellence! Why UnityPoint Health? At UnityPoint Health, you matter. We're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you're in.  Here are just a few: * Expect paid time off, parental leave, 401K matching and an employee recognition program. * Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. * Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Find a fulfilling career and make a difference with UnityPoint Health. Responsibilities * Serves as an internal expert and consultant for accreditation/ CMS conditions of participation and performance improvement (PI) initiatives * Serves as liaison to Medical Staff for Accreditation/PI policy/functions as needed * Provides Accreditation/PI support to hospital and medical staff * Works directly with healthcare team members and physicians to devise, implement, monitor and analyze PI initiatives * Provides clinical expertise/guidance in data collection and interpretation for adherence to standards * Assesses compliance to regulatory standards with recommendations for change * Conducts training in Accreditation, conducts ongoing internal audits and assists at other affiliates upon request * Coordinates Internal Audits, Audit Summary Reports, and applicable action plans * Assists to survey other organizations for compliance to accreditation standards / conditions of participation Qualifications Education: * Bachelors degree in nursing, health care administration, business or health related field is required * MSN, MHA, or Masters degree in health-related field is preferred Experience: * 3 years successful employment in related field * ISO Auditing is preferred License(s)/Certification(s): * Valid driver's license when driving any vehicle for work-related reasons