5-7 years of experience in regulatory compliance leadership in healthcare.
Bachelor's degree in a relevant field is required.
Familiarity with Joint Commission, CMS, IDPH, OSHA, and CDC regulations.
Strong understanding of patient, system, and environment tracers.
Experience managing corrective action plans and audits in clinical settings.
Responsibilities
Lead hospital-wide regulatory compliance initiatives.
Direct readiness efforts for multiple regulatory agencies.
Manage development and oversight of tracer programs.
Conduct annual and focused mock surveys and departmental assessments.
Oversee auditing processes across various clinical and operational areas.
Review and standardize regulatory policies for compliance alignment.
Serve as liaison with regulatory agencies for documentation and survey logistics.
Benefits
Comprehensive health and wellness programs.
Opportunities for professional development and education.
Support for continuing education and certifications.
Flexible working environment with potential for remote work.
Employee assistance programs for mental health and well-being.
Full Job Description
Essential Duties and Responsibilities
Regulatory Compliance Leadership - Lead hospital-wide regulatory compliance and continuous survey readiness.
Survey Readiness Oversight - Direct readiness for Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies.
Tracer Program Management - Develop and oversee patient, system, environment, medication, infection prevention, and high-risk process tracers.
Mock Survey Leadership - Lead annual and focused mock surveys, departmental assessments, and leadership interview preparation.
Regulatory Auditing - Manage audits across clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing.
Corrective Action Plan Management - Develop and track corrective action plans for survey findings, audits, complaints, and citations.
Environment of Care Compliance - Ensure compliance with life safety, emergency management, utilities, fire safety, hazardous materials, and equipment standards.
Regulatory Communications - Serve as liaison with regulatory agencies; manage documentation, evidence submissions, and survey logistics.
Regulatory Education - Provide organization-wide education on Joint Commission, CMS, IDPH, OSHA, and survey readiness.
Regulatory Monitoring - Track regulatory updates and coordinate organizational implementation.
Executive Reporting - Report compliance trends, readiness status, audit findings, and CAP progress to executive leadership.
Leadership Responsibilities - Promote a culture of compliance, mentor leaders, and support strategic improvement initiatives. Minimum Acceptable Qualifications and Education:
