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Trinity Health RN Accreditation & Regulatory Specialist Full Time in Muskegon, Michigan

This professional level nursing opportunity is for a RN Accreditation and Regulatory Specialist at Mercy Health in Muskegon, MI.

Currently there is not an open position, but we do expect one to come open soon.


Bepart of what's next at Mercy Health!

Our newly built medical center will be opening September 2019 visit us at

As a world-class destination for comprehensive health care, the new Mercy Health medical center will be an energy-efficient, green facility comprised of 10 stories featuring 267 expansive, private patient rooms; a new Emergency Department; state-of-the-art surgical and procedural areas; the renovation of the existing Mercy Campus; and a host of modern amenities and technologies. Site preparation on the Mercy Campus began in May 2016 and full-scale construction is currently underway.

Please completely fill out the application and upload resume.

This is required to be considered, including internal candidates.


Provides organization-wide leadership, oversight and monitoring to ensure full compliance of The Joint Commission accreditation and Centers for Medicare and Medicaid rules and regulations. Identifies compliance gaps and develops appropriate plans to address and close the gaps in collaboration with leadership. Develops and implements policies and facilitates standardization of procedures to meet compliance requirements. Identifies/creates education materials and educates providers, staff and leadership to ensure regulatory compliance.



Minimum: Graduate of an accredited school of nursing program.

Bachelors' degree in health care related field or actively pursuing

Preferred: Master's degree in related field


Minimum: Current Michigan licensed Registered Nurse

Preferred: Certification in Health Care Quality and/or training/certification in specific tools

and techniques of performance improvement

Related Experience


  • Three to five years Registered Nurse experience in an acute care setting.
  • In depth knowledge of The Joint Commission rules and regulation
  • Technical knowledge of the principles of process improvement


  • Three years of quality management and the application of performance improvement methodologies, tools, standards and guidelines with the past interation with medical staff and hospital administration.
  • Knowledge of the following: The Joint Commission (TJC) Standards,
  • Centers for Medicare/Medicaid (CMS) Conditions of Participation and Michigan Department of Community Health (MDCH)
  • Proven track record in developing, implementing and managing performance improvement programs at similar sized institutions
  • Demonstrated experience in leading a successful completion of The Joint Commission accreditation review process.

Other Knowledge, Skills and Abilities


  • Demonstrated ability to make timely and effective decisions and takes initiative when there is ambiguity; draw from multidisciplinary expertise to solve problems and develop solutions involving innovative, creative thinking; stay ahead of and knowledgeable in applicable Federal, State and local laws and regulations.
  • Willingness to challenge established ways of doing things in a constructive way
  • Demonstrated ability to analyze, evaluate and problem solve effectively; proven ability to build positive relationships with key stakeholders
  • Ability to develop and implement policies
  • Ability to build effective and collaborative relationships
  • Requires analytical skills and clinical background necessary to interpret clinical data
  • Requires a high level of interpersonal and communication skills in order to provide effective leadership to the system, functions/departments
  • Ability to interpret applicable regulatory standards, recognizes and communicates issues/occurrences to the appropriate parties and assists in identifying a resolution in order to meet standards
  • Demonstrated ability to develop policies designed to promote understanding
  • Excellent interpersonal, verbal and written communication skills
  • Leadership skills to direct and facilitate others towards objectives that contribute to the success of the organization
  • Organizational skills in order to effectively coordinate all aspects of various regulatory compliance
  • Credibility to conduct educational programs for staff at all levels, including medical staff
  • Knowledge of adult learning, educational principles and group facilitation skills


Shows how to use (through a competency assessment) a standard desktop and windows based computer system, including a basic understanding of email, e-learning, intranet and computer navigation. Ability to use other software as required performing the essential functions of the job.


  1. Exposed to a variety of attitudes, personalities and reactions from colleagues and other members of the health care team, patients and family members.

  2. Work with multiple, often-conflicting priorities, under tight timelines.

  3. Ability to manage multiple and sometimes conflicting priorities simultaneously.

  4. Fast-paced work environment with changes in workload, competing priorities and deadline situations.

  5. Subject to interruptions and performing detailed tasks.

  6. Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting and


  1. Position requires some lifting and/or pushing/pulling up to 20 pounds unassisted.

  2. Involves minimal exposure to infectious disease.


  • Serves as the organizational representative and expert assuring compliance with accrediting and regulatory bodies.
  • Supports organization-wide ambulatory sites/clinical departments by developing/implementing/facilitating site audits and/or mock surveys, regulatory analysis and coordination of accreditation requirements.
  • Works in collaboration with key ambulatory leadership to assure regulatory compliance. Leads on-going preparedness for accreditation and regulatory agencies by assessing and ensuring organizational compliance with accreditation standards and regulations including but not limited to Joint Commission and CMS.
  • Responsible for the development, maintenance and communication of relevant regulatory Clinical Policies and Procedures and all company Policies and Procedures and Performance Improvement Plans while maintaining a collaborative relationship with key stakeholders.
  • Researches appropriate procedural prevailing guidelines and makes needed recommendations accordingly. Serves as a champion and change agent for quality and safety by appropriately challenging current processes, policies and procedures.
  • Seeks to incorporate new technologies and methods to improve overall effectiveness.
  • Seeks multidisciplinary expertise as necessary to solve problems and stay ahead of process developments.
  • Actively participates in committees and task forces as assigned. Identifies and reports areas of vulnerability related to accreditation standards and regulations.
  • Develops strategies and plans to close identified gaps, consistently across the organization. Assists key stakeholders with non-clinical policy and procedure development providing regulatory interpretation to ensure policies and procedures meet the appropriate regulatory standard.
  • Develops systems for on-going monitoring of policy and procedure compliance including reporting finds and plans for improvement to leadership.
  • Leads internal Joint Commission team and demonstrates effective listening skills to individuals or groups, considers various points of view and assimilates information into clear, concise, useable action items utilizing process improvement methodologies.
  • Develops, implements and conducts training programs consistent with organizational needs related to regulatory compliance and clinical.
  • Assists in development of quality tools, analysis and display of data and writing of process improvement reports and plans; develops presentation materials in a readily comprehensible way and professional manner.
  • Facilitates personal professional development.
  • Performs all other duties as assigned.


Job Number: 00093942

Location: Muskegon, MI

Organization Name: Mercy Health

Facility: MHWMI - MHP Mercy Campus

Employment Type: Full time

Shift: Day Shift

Hours: 40