Quality and Patient Safety Specialist

Accreditation And Regulatory Consultant

Location: University Hospital Onsite

Shift: Day shift Mon-Fri

IU Health is Indiana's largest and most comprehensive healthcare system, committed to maintaining the highest standards of accreditation and regulatory compliance. We are seeking a dedicated accreditation and regulatory professional to facilitate compliance activities, support survey readiness, and serve as a liaison with regulatory agencies across facilities.

Position Overview:

The Accreditation and Regulatory Consultant oversees accreditation and regulatory compliance activities within assigned facilities and provides interfacility readiness support across IU Health. This role involves education, consultation, and advisement with key stakeholders on interpretations of accreditation and regulatory standards, coordinating survey preparation, managing onsite surveys, and ensuring comprehensive post-survey follow-up. The consultant proactively reviews new or revised services and spaces for compliance, participates in performance improvement activities, and provides regular updates to leadership on compliance status. They serve as the primary liaison for communication with the Indiana Department of Health and other accrediting organizations.

Key Responsibilities:

Facilitate accreditation and regulatory compliance activities within assigned facilities.

Provide education, consultation, and advisement to stakeholders and leaders on standards and survey readiness.

Coordinate and manage onsite survey activities, including preparation and post-survey follow-up, including corrective action plans.

Review new or revised services and spaces for compliance with applicable standards.

Participate in performance improvement activities to achieve or restore compliance.

Serve as the facility liaison for communication with the Indiana Department of Health and accrediting agencies.

Provide periodic updates to leadership regarding compliance and readiness status.

Support organization-wide compliance initiatives and continuous improvement efforts.

Qualifications & Requirements:

Education:

- Bachelors Degree required.

Experience & Certifications:

- 3-5 years of relevant experience in healthcare compliance or accreditation.

- Healthcare regulatory certification such as Certified Professional in Healthcare Quality (CPHQ) or similar endorsed by IU Health System Regulatory Affairs required within two years of employment.

- Healthcare Leadership Experience Preferred

Licensure & Licenses:

- Current state of Indiana license as a healthcare professional (e.g., RN with active Indiana license, Respiratory Therapist, Pharmacist, or Rehabilitation license).

Additional Requirements:

- Interfacility travel for surveying and in-state overnight stays is required.

Why Join IU Health?

Play a vital role in ensuring compliance and excellence in patient safety.

Support continuous improvement across multiple facilities.

Collaborate with dedicated professionals committed to quality care.

Contribute to maintaining IU Health's reputation for regulatory excellence.