Job Description

SUMMARY:

The Manager, Regulatory and Emergency Management is responsible for the leadership, coordination, and oversight
of La Rabida Children's Hospital's regulatory compliance, accreditation readiness, licensure management, and
emergency preparedness programs. Reporting to the COO, this position promotes continuous readiness for
accreditation and regulatory surveys, supports patient safety and high reliability initiatives, and directs the hospital's
comprehensive emergency management program.
The Manager serves as an organizational resource for regulatory standards, accreditation requirements, emergency
preparedness activities, and performance improvement initiatives. Working collaboratively with leaders, physicians,
employees, and external agencies, the position ensures ongoing compliance with regulatory and accreditation
requirements while strengthening organizational preparedness, resilience, and patient safety.

ESSENTIAL FUNCTIONS:
Regulatory Compliance & Accreditation Readiness
• Direct and oversee the hospital-wide regulatory compliance and accreditation readiness program.
• Ensure continuous compliance with The Joint Commission, CMS Conditions of Participation, Illinois
Department of Public Health requirements, and other applicable regulatory standards.
• Lead planning, preparation, coordination, and follow-up activities for accreditation surveys, regulatory
inspections, and validation reviews.
• Serve as the primary liaison for regulatory and accreditation agencies and coordinate organizational
responses to survey findings.
• Oversee hospital licensure, certifications, permits, registrations, and required regulatory submissions.
• Monitor regulatory changes and communicate new requirements to organizational leaders and stakeholders.

Continuous Readiness, Assessment & Performance Improvement
• Conduct regulatory rounds, tracers, mock surveys, environmental tours, audits, and gap assessments to
evaluate organizational compliance and readiness.
• Review policies, procedures, clinical documentation, and operational practices to identify regulatory
vulnerabilities and opportunities for improvement.
• Develop corrective action plans and monitor implementation to ensure sustained compliance.
• Lead regulatory performance improvement initiatives utilizing evidence-based practices, risk reduction
strategies, and High Reliability Organization principles.
• Analyze compliance findings, survey outcomes, and organizational data to identify trends, prioritize risks,
and support leadership decision-making.
• Develop and maintain compliance dashboards, scorecards, reports, and readiness metrics.

Emergency Management & Preparedness
• Develop, implement, and maintain the hospital's Emergency Management Program and Emergency
Operations Plan (EOP).
• Ensure compliance with CMS Emergency Preparedness requirements, The Joint Commission standards,
OSHA requirements, and applicable federal, state, and local regulations.
• Conduct annual Hazard Vulnerability Analyses (HVA) and risk assessments to identify threats and
vulnerabilities and develop mitigation strategies.
• Develop and maintain emergency preparedness policies, procedures, and response plans.
• Coordinate emergency preparedness activities across all hospital departments to support organizational
readiness and resilience.
• Manage emergency preparedness grants, programs, and reporting requirements as applicable.

Training, Response & Community Coordination
• Plan, facilitate, and evaluate emergency preparedness training, tabletop exercises, functional exercises, and
full-scale disaster drills.
• Educate staff regarding emergency response procedures, Hospital Incident Command System (HICS) roles,
and individual responsibilities during emergencies.
• Maintain the Hospital Incident Command System structure and support activation, response, recovery, and
after-action activities during emergency events.
• Serve as the primary liaison with healthcare coalitions, public health agencies, emergency management
organizations, and community partners.
• Coordinate emergency communications, surge planning, resource management, and continuity of operations
activities.
• Lead post-event evaluations, corrective action planning, and after-action reporting to strengthen future
preparedness efforts.

ADDITIONAL FUNCTIONS:
• Participates in hospital committees, task forces, accreditation teams, and multidisciplinary workgroups.
• Provides consultation and education to leaders and staff on regulatory compliance, accreditation standards,
and emergency preparedness requirements.
• Assists with organizational initiatives related to patient safety, quality improvement, risk reduction, and
operational excellence.
• Represents the hospital during external meetings, surveys, healthcare coalition activities, and emergency
preparedness events.
• Performs other duties as assigned in support of organizational priorities.

Qualifications

Education: Bachelor's degree, Healthcare Administration, Public Health,
Emergency Management, Quality Management, or related
field required. Master's degree preferred.

Related Work Experience: • Minimum five (5) years of progressive experience in
healthcare regulatory compliance, accreditation,
quality, patient safety, emergency management, or
related healthcare operations.
• Experience leading accreditation surveys, regulatory
readiness programs, tracers, mock surveys, or
emergency preparedness activities required.
• Experience in a hospital setting required.
• Pediatric healthcare experience preferred.

Licensure/Certification:
• FEMA IS-100, IS-200, IS-700, and IS-800 preferred or
obtained within established timeframe.
CPR required:None Required
PALS required: None Required

Preferred Qualifications:
• Certified Professional in Healthcare Quality
(CPHQ).
• Certified Professional in Patient Safety (CPPS).
• Certified Healthcare Emergency Professional
(CHEP), Certified Healthcare Emergency
Coordinator (CHEC), or Certified Emergency
Manager (CEM).
• Knowledge of Joint Commission standards,
CMS Conditions of Participation, OSHA
standards, High Reliability Organization
principles, and emergency preparedness
regulations.

Additional Information

La Rabida is a place unlike any other. We understand the needs of families with children dealing with the most serious or complicated of conditions. With teams of the best healthcare providers in Chicago, we give continuous, comprehensive care, education, and support, helping families face their unique obstacles head-on.