Accreditation and Regulatory Senior Consultant

Location: Methodist Hospital
Position: Consultant-Accreditation and Regulatory Senior

Shift: Full-time Days 

IU Health is Indiana’s largest and most comprehensive healthcare system, and the #1 ranked healthcare provider in the state. We are seeking a dedicated professional to lead our system-wide accreditation and continuous readiness efforts, ensuring organizational excellence and compliance.

Position Overview

The Consultant-Accreditation and Regulatory Senior plans, implements, and directs activities that support the organization’s successful accreditation status and ongoing readiness for patient care. This role consults with key stakeholders and leaders on accreditation and regulatory interpretations, facilitates survey preparations, manages onsite survey activities, and acts as a liaison with accreditation and regulatory bodies. Additionally, the leader analyzes performance data, drives quality improvement initiatives, and provides strategic recommendations to enhance organizational outcomes. They serve as a subject matter expert on accreditation matters, promoting acceptance and understanding across the organization.

Key Responsibilities:

• Lead system-wide accreditation and regulatory compliance efforts.
• Educate and advise stakeholders and leadership on accreditation standards and survey requirements.
• Facilitate survey preparation activities and manage onsite survey processes.
• Serve as a liaison between the organization and accreditation/regulatory bodies.
• Analyze performance metrics and recommend improvements aligned with accreditation standards.
• Drive performance improvement initiatives that support organizational goals.
• Promote a culture of continuous quality improvement and organizational excellence.
• Build stakeholder engagement and serve as an accreditation expert for leaders and teams.

Qualifications & Requirements:

• Education:  
  • Bachelor's Degree in Nursing or a healthcare-related field required.
  • Master’s Degree preferred.
• Experience:  
  • 7-10 years of experience in clinical operations and/or healthcare quality.
  • Proven experience leading complex projects and systematic performance improvement initiatives.
• Licensure:  
  • Current state of Indiana healthcare professional license (e.g., RN license, Respiratory Therapist, Pharmacist, or Rehabilitation license).
• Certifications:  
  • Certified Professional in Healthcare Quality (CPHQ) required.

Why Join IU Health?

• 401(k) retirement savings with employer match
• Tuition reimbursement
• Student loan forgiveness programs (for qualifying participants)
• Employee Assistance Program (free counseling services)
• Healthy Results wellness program, with financial incentives for participation

To learn more about our benefits, visit: careers.iuhealth.org/pages/benefits-designed-for-you

• Indiana University Health has nearly 40,000 team members, including more than 3,600 physicians and 1,200 advanced practice providers, and we’re home to the largest nursing network in Indiana with more than 9,000 nursing team members at over 800 sites of care.
• IU Health is ranked No. 1 in Indiana by U.S. News & World Report, Riley Children's Health is ranked among the top children's hospitals in the country by U.S. News & World Report.
• A unique partnership with the Indiana University School of Medicine – one of the nation’s largest medical schools – gives patients access to groundbreaking research and innovative treatments, and it offers team members access to the latest science and the very best training – advancing healthcare for all.
• With 15 hospitals, including seven with Magnet designation and eight with Pathways to Excellence designation, our team members are leading the way through excellence.
• At Indi