Job Information

Sanford Health Lead Accreditation Specialist in Bemidji, Minnesota

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Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

Facility: Lake Region Office Bldg
Location: Bemidji, MN
Address: 3807 Greenleaf Ave NW, Bemidji, MN 56601, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00

Job Summary

Leads programmatic oversight of a regional accreditation program. Responsible to coordinate the work of the accreditation team in order to lead the specific market to a continual state of regulatory readiness. Collaborates with operational and executive leaders ensuring compliance with regulatory bodies to include, but not limited to: Department of Health (DOH), Center for Medicare and Medicaid (CMS) Conditions of Participation, and standards of The Joint Commission (TJC) as applicable. Communicates new and pending standard interpretations, updates, clarifications and issues of concern to appropriate stakeholders.

Quantitatively and qualitatively, assesses compliance followed by communicating results. The Lead facilitates regulatory readiness activities. Works with staff, evaluating care, to ensure regulatory compliance (tracers).

Evaluates patent safety systems ensuring safe reliable care. Promotes systems designed to reduce the opportunity for human failure in order to achieve a goal of zero harm. Understands and supports an organizational culture of safety. Participates in robust process improvement, utilizing a systematic approach to change management, focused on reducing patent safety and regulatory risk. Supports process change from education through sustainability. Collaborates with all levels of leadership to communicate needs and remove barriers for staff.

Presents regulatory perspective to committees as applicable. Organizes system education and strategies towards achieving a constant state of regulatory readiness.

Requires a self-motivated individual who values patent and staff safety as the top organizational priority. Knowledge and/or an interest in safe systems and High Reliability Organizations necessary. Must have a passion for patent and staff safety. Periodic overnight travel is required.


Graduate from an American Association of Colleges of Nursing (AACN) or National League for Nursing (NLN) accredited

college of nursing. Master's Degree in nursing or a health related field preferred.

Three years of experience in regulatory compliance, quality management, and performance improvement preferred. Experience in a management or leadership position in healthcare preferred. Experience in accreditation and healthcare regulation desired. Previous Clinical Nursing experience required.

Currently holds an unencumbered Registered Nurse (RN) license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state.

(RN preferred but not required.)

Certification in regulatory, patient safety or quality specialty preferred, must obtain within three years of hire date. Resources Outsourcing (HRO), change management, Just Culture, Certified Professional in Healthcare Quality (CPHQ), LEAN, Six Sigma and Human Factors desired.


Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, sick leave and paid time off. To review your benefit eligibility, visit .

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 1-877-673-0854 or send an email to .

Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.

Job Function: Legal and Compliance
Req Number: R-70516
Featured: No