The Market Director, Regulatory & Accreditation provides strategic leadership and operational oversight for regulatory compliance, accreditation readiness, and survey management across a designated market of hospitals, ambulatory facilities, and affiliated healthcare entities. This leader partners with executive, clinical, operational, and physician leadership to ensure continuous compliance with federal, state, and accreditation requirements while fostering a culture of quality, patient safety, and operational excellence. Dotted line reporting structure to Corporate Sr. Director, Regulatory and Accreditation.
PRIMARY RESPONSIBILITIES Regulatory and Accreditation Compliance- Direct market-wide regulatory compliance activities to ensure adherence to federal, state, and local regulations.
- Monitor changes in regulatory requirements and assess organizational impact.
- Develop and implement compliance strategies, policies, and procedures.
- Serve as a subject matter expert on regulatory and accreditation requirements, including CMS Conditions of Participation, state licensing regulations, and other healthcare regulations.
- Ensure timely and accurate completion of corrective action plans and evidence of standards compliance.
- Lead regulatory and accreditation readiness efforts for organizations
- Coordinate mock surveys, tracers, gap assessments, and continuous survey readiness activities.
- Oversee accreditation application, renewal, and maintenance processes.
- Lead regulatory and accreditation survey preparation, execution, and response activities.
- Coordinate survey command center operations during announced and unannounced surveys.
- Serve as primary market liaison for surveyors and regulatory agencies.
- Direct development and implementation of plans of correction and sustainable corrective actions.
- Collaborate closely with corporate regulatory and accreditation leadership
Organizational Integration- Collaborate with quality, patient safety, risk management, infection prevention, and clinical operations leaders to address compliance risks.
- Analyze regulatory findings, trends, and organizational vulnerabilities to drive improvement initiatives.
- Support enterprise quality and patient safety objectives through proactive risk mitigation.
Leadership and Consultation- Provide consultation and guidance to facility executives, department leaders, and governing boards.
- Lead and mentor regulatory and accreditation staff across the market.
- Facilitate education programs related to regulatory compliance and accreditation standards.
- Foster collaboration among hospitals, ambulatory facilities, and corporate departments.
Performance Improvement- Develop market-wide compliance dashboards, metrics, and monitoring systems.
- Identify opportunities to improve regulatory performance and reduce organizational risk.
- Utilize data analytics to prioritize compliance activities and resource allocation.
- Lead special projects and strategic initiatives related to quality, safety, and compliance.
Qualifications:REQUIRED EDUCATION: Registered Nurse with Master's Degree in Nursing, Healthcare Administration, Business Administration, or other relevant healthcare field plus five years of regulatory, accreditation, and performance improvement experience
MINIMUM EXPERIENCE: 7 years of progressive healthcare leadership experience with 5 years of experience leading hospital regulatory compliance, accreditation, quality, patient safety, or healthcare operations
PREFERRED EXPERIENCE: Multi-facility, market, or system level leadership experience strongly preferred
REQUIRED CERTIFICATIONS/LICENSURE: CPHQ, CPPS, or CPHRM certification within 12 months of hire
Facility Description: DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure.
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