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Accreditation/ISO Compliance Officer | Le Bonheur Job

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Date: Jul 22, 2022

Location: US

Company: Methodist Le Bonheur Healthcare


Leads and designs processes related to accreditation and ISO:9001 compliance, including the Quality Management System and Internal Audit at both the System level and assigned facility. Serves as the subject matter expert in CMS Conditions of Participation, ISO: 9001, NIAHO, State agency, Internal Audits and other accreditation and certification requirements. Plans, directs, and implements risk-prioritized processes to support ongoing compliance and Quality Management System. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.



Education/Formal Training

Work Experience



Bachelor’s degree in Nursing or Allied Health area Healthcare Administration, or closely related field.

Minimum of three years progressively responsible experience in organizing, directing and participation in process improvement and/or regulatory compliance program in a hospital setting.



Master’s degree in Nursing, Allied Health area, Healthcare Administration, or closely related field.


Certified Professional in Healthcare Quality (CPHQ) from National Association for Healthcare Quality


In lieu of degree, High school graduate or equivalent will be accepted with seven (7) year’s job relevant experience


In lieu of degree, Registered Nurse or Allied Health Professional will be accepted with five (5) year’s job relevant experience.





  • Demonstrated knowledge and expertise in CMS Conditions of Participation, ISO: 9001, NIAHO/State Agency/Internal Audit and other accreditation certification requirements.
  • Strong communication skills including excellent verbal, written and presentation abilities with experience in conveying complex information to all Associates, from management to frontline.
  • Demonstrated capability in a collaborative approach to Quality Management Systems, including facilitation of corrective action planning, verifications of control, internal audit, and regulatory compliance.
  • Ability to consult, negotiate, and influence in situations deemed controversial and/or sensitive to achieve mutual decisions.
  • Ability to exercise discretion in what and how to communicate and educate.
  • Ability to interpret and apply complex statutes, regulations, standards, and certification requirements.
  • Applies risk-based thinking in all process design and management of internal audit and non-conformances.
  • Ability to work without close supervision and to exercise independent judgement.
  • Ability to organize multiple tasks and projects, manage time, and maintain control of own workflow.

Key Job Responsibilities

  • Leads and directs the process for continuous accreditation and ISO:9001 compliance at both the system level and for assigned facility(s).
  • Develops and coordinates the measurement of internal compliance through data collection, tracking/trending, analysis, and monitoring. Presents findings and recommendations for improvement.
  • Applies risk-based thinking to prioritize, design, and lead internal audits across the system; report results and facilitate corrective action plans.
  • Upon identification of non-conformities, works with appropriate stakeholders to facilitate development of correction action plans and verifications of control.
  • Educates all levels of Associates (leaders to frontline) on the principles and requirements of the Quality Management System, ISO: 9001, and accreditation standards and the processes required for compliance.
  • Provides presentations and updates to facility/system leadership and management review committees regarding accreditation/ISO:9001 results & compliance, internal audits/corrective action plans status, and any component of the Quality Management System.
  • Leads the Hospital’s response to CMS investigations.
  • Designs/develops processes and coordinates external audits (DNV, ISO: 9001).
  • Provides expertise/advice during the development of clinical/operational/business policies and procedures to ensure CMS Conditions of Participation and accreditation, and ISO:9001 standards are met or exceeded.

Physical Requirements

  • The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
  • Must have good balance and coordination.
  • The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
  • The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
  • The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.

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