Ascension Health Specialist-Compliance / St John Hospital & Medical Center / FT Days in Detroit, Michigan

Additional Job Information

Title: Spclst-Compliance

City, State: Detroit, MI

Location: St John Hospital & Medical Center

Department: Medical Affairs Admin

Additional Job Details: FT Days

Marketing Statement

St. John Providence Health System is a member of Ascension Health, the largest not-for-profit Catholic Health system in the United States.

Our Mission, Vision and Values: St. John Providence Health System, as a Catholic health ministry, is committed to providing spiritually centered, holistic care which sustains and improves the health of individuals in the communities we serve, with special attention to the poor and vulnerable.

Our Values: We are called to: Service of the Poor, Reverence, Integrity, Wisdom, Creativity and Dedication

Our Vision: Our passion for healing calls us to cultivate trust, advocate wellness, and transform healthcare.

Job Description

Job Summary:

The Spclst-Compliance 2 develops and oversees activities designed to promote regulatory compliance and continual survey readiness.

Responsibilities :

  • Stays informed of regulatory/standards changes and interprets applicability of changes across patient care, ancillary and general departments.

  • Ensures readiness at all organizational levels for regulatory changes and applies innovative methods for implementation.

  • Guides action plan development, performance monitoring and reporting when deficiencies are identified.

  • Collaborates on identifying best practices and streamlines survey preparation.

  • Acts as liaison to Gift of Life Michigan (GOL), Keystone, etc., to facilitate above-mentioned initiatives for purposes of potential donor candidate quality improvement and the study and evaluation of the size of potential organ donor pool. Utilize GOL election database to track and verify potential referrals. Submit reports to GOL as requested.

  • Develops and coordinates the organ and tissue donation initiatives within SJH&MC, which includes but is not limited to: chart audits, data management, related policy review/revision, related form review/revision, action plan development, communication, and education. Reports to the organ and tissue committee and quality committee of the board (at least annually).

  • Develops, coordinates, and assists in implementing an on-going regulatory compliance program for SJPHS East Region hospital-based physician practices. Monitors and interprets external agency standards/conditions including: The Joint Commission, CMS, MDCH, HFAP, etc. Assists in implementing continuous operational improvement as well as self-assessment of hospital-based physician practices.Supports hospital-based physician practice leadership to achieve a constant state of readiness as it pertains to standards/regulatory complianceCoordinates survey preparation, on-site survey activities and survey follow-up.Works with appropriate hospital-based physician practice leaders to monitor and report on corrective action planning efforts.Coordinates hospital-based physician practice Tracer-Rounding activities. Tracks, trends, and analyzes the findings and communicates to leadership.Consults, advises, and coaches hospital-based physician practices on the intent of standards and survey preparation necessary to achieve compliance.



  • Bachelor's degree in a healthcare, business, or education related field required, or equivalent professional level experience required

Work Experience:

  • 3 years of experience in related field.

How To Apply

If you are interested in joining the St. John Providence Health System team, please apply by completing an online application at

If you have questions about the application process or require a reasonable accommodation to complete the application, please contact the Ascension Health Ministry Service Center at 1-855-562-2824 between the hours of 7:30 am and 8:00 pm EST Monday-Friday.

Equal Employment Opportunity

St. John Providence Health System is an equal opportunity and affirmative action employer. We provide equal employment opportunities to all associates and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, height, weight, genetic information, marital status, amnesty, veteran status or any other legally protected status in accordance with applicable federal, state and local laws. The information requested on this application will not be used for any purpose prohibited by law. If you require assistance or an accommodation to complete this application, please let us know.

For further information regarding your EEO rights, click on the following link to the “EEO is the Law” poster:


EEO is the Law Poster Supplement

Reasonable Accommodation

St. John Providence Health System provides reasonable accommodation so that qualified applicants with a disability may participate in the selection process. Please advise us of any accommodations you request in order to express interest in a position by e-mailing: . Please state your request for assistance in your message. Only reasonable accommodation requests related to applying for a specific position within St. John Providence Health System will be reviewed at the e-mail address supplied.

Thank you for considering a career with St. John Providence Health System.

Please note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.

E-Verify Statement

St. John Providence Health System participates in the Electronic Employment Verification Program. Please click the E-Verify link below for more information.

E -Verify (link to E-verify site)