Process Improvement & Accreditation Specialist
About The Position
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 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.
Requirements
- Associate’s degree in health information administration, healthcare administration, business, nursing or respiratory required
- Licensed as a registered nurse or healthcare professional required
Nice To Haves
- Bachelor’s degree preferred
Responsibilities
- Drives continuous survey readiness by managing regulatory compliance, conducting tracers, and ensuring adherence to TJC and CMS standards.
- Supports systematic organization-wide performance improvement.
- Supports 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
