Job Description

Position Title: Director, Accreditation & Regulatory Compliance

Department: Administration / Compliance Safety Sensitive: ☒ Yes • No

Reports to: Chief Administrative Officer (CAO) Exempt Status: ☒ Yes • No

The Director of Accreditation & Regulatory Compliance provides strategic leadership and organizational oversight for all accreditation, certification, and regulatory compliance activities in a DNV-accredited hospital. This role ensures sustained compliance with DNV NIAHO® requirements, CMS Conditions of Participation, ISO 9001 Quality Management System standards, and applicable state and federal regulations, while fostering a culture of continuous readiness and risk-based improvement.

The Director serves as the enterprise leader for accreditation strategy, survey readiness, and regulatory risk mitigation, coordinating across clinical, operational, and administrative departments.

Health and Well-Being Benefits at KRMC

• Medical, Dental, Vision
• Wellness and Employee Assistance Program
• Employer Paid Group Life
• Short & Long-Term Disability
• Paid Time Off
• 403b Retirement Plan with Employer Contributions
• Employee Discounts
• Employee Referral Bonus Program
• Identity Theft Protection Program
• On-site daycare exclusive to our employees' children from 6 months to school age! (fees apply)
• Discounted membership to on-site gym/wellness center with childcare

Career Growth and Development Benefits at KRMC

• Tuition Reimbursement for full-time employees
• Scholarships available
• Student Loan Forgiveness; As a not-for-profit organization, our employees who have qualified student loans, may be eligible for a Public Service Loan Forgiveness program

Key Responsibilities

• Strategic Leadership & Governance: Provide executive level oversight of accreditation and regulatory compliance programs, ensuring alignment with organizational priorities and enterprise risk management.; advise the CAO and senior leadership on accreditation risks, regulatory changes, and compliance trends; Serve as the organizational authority for DNV, CMS, ISO, and state regulatory interpretation.
• Accreditation & Survey Oversight: Direct all activities related to DNV NIAHO® accreditation, CMS validation surveys, ISO 9001 certification, and state licensure surveys; oversee enterprise-wide survey readiness using a "ready every day" approach; provide executive oversight during on-site surveys, including surveyor coordination, leadership briefings, issue resolution, and reporting requirements.
• Program Management & Continuous Readiness: Ensure the design, implementation, and sustainability of internal audit, mock survey, and tracer programs; monitor corrective action plans, risk trends, and sustainability of improvements; ensure accreditation requirements are embedded into operational workflows rather than treated as episodic activities
• Leadership of Accreditation & Audit Functions: provide direct leadership and performance oversight to the Accreditation Manager and Internal Auditor; ensure clear role delineation between strategic oversight (Director), program execution (Manager), and validation (Auditor); support staff competency development related to regulatory standards and survey preparedness.
• Policy, Standards & Regulatory Integration: oversee development, review, and governance of policies and procedures to ensure alignment with regulatory and accreditation standards; ensure document control and evidence management support survey readiness and traceability; collaborate with Nursing, Operational Clinical Departments, Quality, Risk, Safety, Infection Prevention, Facilities, IT, and Medical Staff leadership to ensure integrated compliance.
• Education & Organizational Engagement: ensure leaders and staff receive accurate, timely education regarding regulatory and accreditation requirements; promote organizational understanding of DNV's management-system-based approach and risk-based thinking.
• Performs other duties as assigned to support overall effectiveness of department and organization.

Required Qualifications

Education: Bachelor's degree in healthcare administration, nursing, quality, or related field.

Experience: Minimum 7-10 years of progressive experience in hospital accreditation, regulatory compliance, or quality management. Demonstrated leadership experience in a DNV-accredited hospital environment.

Knowledge, Skills, and Abilities

Strong working knowledge of:

• DNV NIAHO® standards
• CMS Conditions of Participation
• ISO 9001 Quality Management Systems
• Applicable NFPA Facilities Working Knowledge

Preferences

Education: Master's degree in healthcare administration, nursing, public health, or related field.

Experience: Experience leading organizations through accreditation surveys with minimal findings.

Certification: Professional certifications such as CHOP, CHOP B, CPHQ, CPPS, CHC, or equivalent.

Knowledge, Skills, and Abilities:

• Skill in driving accountability across departments without direct operational control
• Experience integrating accreditation requirements into operational workflows
• Experience building internal audit, tracer, and monitoring programs that demonstrate system effectiveness

Special Position Requirements

Exposure Category III: Expected duties do not have potential for exposure to blood, body fluids or tissues.

Work Requirements

• Must be able to see and read reports, computer display terminals, and have manual dexterity to keypunch data via a keyboard.
• Hearing and verbal ability to interact with staff, managers, patients, and vendors.
• Must be able to stand or walk continuously Requires mobility to meet with management at their service area throughout the Health System.
• Must be able to sit for extended periods of time. May require extended periods of sedentary work and extended working hours to meet stated objectives.
• Able to demonstrate manual dexterity and mechanical ability.
• Must be able to lift 35 pounds

Date Staff Position Description Created / Revised: 03/09/2026