Director - Accreditation / Regulation

Universal Health Services   •  

San Antonio, TX

Industry: Healthcare


8 - 10 years

Posted 166 days ago

This job is no longer available.

Job Description

The Director of Accreditation & Regulation is responsible for leading all Acute Division Accreditation & Regulation activities. The position develops, educates, implements and monitors regulatory requirements and accreditation standards, goals and targets. This includes the creation of a state of survey readiness that establishes processes for safe practices. Tracks progression and sustainment of UHS regulatory and accreditation strategy and tactics through an active Tracer Program and standardized reporting process. 

Essential Job Duties

  • Works collaboratively with corporate and hospital administration, medical staff, risk management, and other facility leaders to achieve continuous compliance with accrediting and regulatory requirements
  • Provides orientation and training for new Quality directors and accreditation staff and assists to promote their professional development, safety and clinical improvement
  • Serves as the corporate Joint commission liaison and interacts with the assigned Joint Commission account representative as necessary on behalf of the company and facilities
  • Directs and supports a culture of patient safety through the implementation of a “continuous readiness” framework and best practice for continued readiness 
  • Coordinates and conducts collaborative patient safety surveys to assess that the facility is compliant with accreditation standards and the regulations of federal, state, local and other regulatory bodies with jurisdiction over its clinical activities as requested by corporate leadership
  • Provides post survey recommendations for sustainable safety initiatives through written reports and ongoing conference calls with the facility quality, accreditation and leadership staffs
  • Assists the facilities in formulating plans of corrections, evidence of standards compliance and complaint responses such as those received from accrediting organizations, and State and Federal agencies. Collaborates with subject matter experts as needed
  • Provides consultative recommendations related to the Periodic Performance Review and associated action plans non-compliant standards
  • Develops and supports the tracer system for regular and systematic collection, analysis, and reporting of compliance data



Master's degree in Nursing, hospital administration, or public health with 8 - 10 years' experience.

  • Expert knowledge of The Joint Commission Standards
  • Expert knowledge of CMS Conditions of Participation
  • Proficiency with the Cerner electronic medical record
  • Leadership/Management experience preferably in an administrative role
  • Requires excellent analytic, problem solving, organizational and project management skills
  • Skilled in developing corrective action plans and directing performance improvement activities
  • Knowledge of Office Word, Excel, PowerPoint and statistical analysis programs, with strong overall computer skills
  • Travel: 30- 50%