Sanford Health

RN Accreditation Specialist - Accreditation

Fargo, North Dakota
Join our team!
Feb 21, 2018
Job Type

Oversee assigned entity compliance with Department of Health (DOH) statutory requirements, Center for Medicare and Medicaid (CMS) Conditions of Participation and standards of The Joint Commission (TJC) as applicable to the entity. In addition, shall serve in a facilitation role to support and coordinate with those within the organization/entity who have primary responsibility for additional service, department or disease-specific accreditations and certifications. Assists in the coordination efforts of additional clinical and support roles to include health and safety, performance improvement, quality, infection prevention and control, compliance and entity clinical services roles to meet DOH, CMS and TJC compliance needs. Works closely with entity leaders to ensure operations are designed and implemented to support accreditation and certification compliance standards.Accountability to entity executive leaders charged with overall accreditation standards compliance. Responsibilities include: maintaining a current working knowledge of applicable regulations to include state specific DOH statute, CMS Conditions of Participation and TJC standards; communicating new and pending standard interpretations, updates, clarifications and issues of concern to individuals and groups; coordinating monitoring activities to quantitatively and qualitatively assess compliance; preparing discrepancy reports upon which management may act; facilitating process improvement changes to enhance regulatory compliance; facilitating development and implementation of related action plans; and coordinating organization-wide efforts to maintain a constant state of readiness.


The Accreditation specialist reports to the Accreditation Manager.

The position requires an individual who excels at creating and maintaining relationships with operations across the system.

The Accreditation department is responsible for aiding in the delivery of safe patient care as directed by the Center for Medicare and Medicaid services (CMS) and The Joint Commission.

Primary responsibilities of the specialist include:

Willingness to learn about regulatory requirements and how they translate into operational practice.

Participate in regulatory readiness activities such as patient tracers and mock surveys.

Provide guidance on standards interpretation.

Partner with operational leaders and point of service staff in achieving standards compliance.

Learn about the principles of change management, Just Culture, and High Reliability.

Some overnight travel is required

Supporting system Emergency management is required as needed.

  • Partner with operations for the education, coordination, and implementation of patient safety initiatives based on organizational need, new standards, survey findings, and standardization.

  • Lead and participate in committees and task forces supporting regulatory compliance/readiness.

  • Coordinate and partner with additional clinical and support roles/departments to include health and safety, risk management, legal, performance improvement, quality, infection prevention, compliance, and clinical services roles to meet regulatory needs.


    Requires current licensure as a Registered Nurse in the state, or states, of practice. The RN functions within the scope and standards of nursing practice as outlined in the respective state's Nurse Practice Act and Administrative Rules. The Sanford Nursing Practice recognizes the Scope and Standards of Practice (2004) and the Code of Ethics for Nurses with Interpretive Statements (2001) as published by the American Nurses Association as the foundation for nursing care delivery. Certification as a Certified Joint Commission Professional(CJCP) is highly recommended. Graduate from an American Association of Colleges of nursing or National League for Nursing accredited college of nursing. Master's degree in nursing or a health related field preferred. Three to five years' experience in regulatory compliance, quality management, and performance improvement or in a management or leadership position in healthcare preferred.

    About Sanford Health:

    At Sanford Health, we are dedicated to the work of health and healing. Every day, we show that commitment by delivering the highest quality of care to the communities we serve. We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care, leading-edge technologies and world-class facilities.

    In addition to strong clinical care, we are also committed to research, education and community growth. We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases. We continuously seek new ways to achieve our vision of improving the human condition here in your community, across the region and around the world.

    The entire team at Sanford Health recognizes the value of healthy families and communities. We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.

    Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-243-1372 or send an email to .

    In compliance with federal law requiring employers to verify new employees' U.S. employment eligibility, Sanford participates in E-Verify. To learn more click here for English Version at or here for Spanish Version at .
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