Job Summary:

Provides direction, leadership, and oversight for all activities related to continuous accreditation, regulatory readiness, and regulatory response across the network. Provides operational oversight for accreditation, regulatory compliance, and hospital licensure activities across multiple hospitals and sites of care within the network. Ensures compliance with the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other external regulatory and accrediting bodies. Leads processes to prepare for accreditation and licensing, sustain compliance with submitted plans of correction, and drive ongoing performance improvement initiatives. Partnering closely with nursing, medical staff, quality and safety leaders, and facility leadership, the Director develops, implements, and validates systems that embed compliance and regulatory excellence into daily operations. Supervises and directs the activities of assigned personnel, providing both professional expertise, mentorship and managerial leadership. Serves as a system resource and may be deployed to other networks, as needed, to support organizational readiness, survey activities, and regulatory compliance.

Job Requirements:

Education and Work Experience:

• Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Five years' of experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Required
• Seven years' of health care or related experience: Preferred
• Leadership experience in acute care Regulatory, quality, and/or performance improvement: Preferred

Licenses/Certifications:

• Certified Professional in Healthcare Quality (CPHQ) or Healthcare Accreditation Certificated Professional (HACP) certification: Required within two years of hire
• Certified Professional in Healthcare Quality (CPHQ) or HACP: Required

Essential Functions:

• Provides administration and oversight of all activities concerning the achievement of continuous accreditation and regulatory survey readiness. Coordinates regulatory and accreditation survey readiness program across multiple communities, including, but not limited to, education of regulatory and accreditation requirements, survey management, rounding, audits, validation of plan of correction sustainability and mock surveys. Manages the network's tracer process and audits where appropriate. Maintains responsibility for the development, communication, implementation and tracking of action plans necessary to close identified gaps in compliance. Trends and analyzes gaps to determine if isolated, pattern or ongoing.
• Strategizes with leadership actions needed to close the gaps. Keeps updated with regulatory changes and assesses impact to the facilities. Takes necessary steps to ensure compliance with those changes, such as policies and procedures, education and process changes. Actively involved in survey process, ensures survey is managed, requests from surveyor are fulfilled and completes necessary follow ups. Reviews survey reports and plans of correction, as required.
• Directs operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organization, along with safety policies and procedures and professional standards of the organization. Maintains knowledge of current accreditation and regulatory trends, guidance, standards, and requirements to ensure facility survey readiness and regulatory compliance and collaborates with Adventist health Accreditation and regulatory team.
• Develops and leads CMS, TJC, and state hospital licensure and regulatory compliance activities for the network hospitals and sites of care that fall under the hospital license. Creates reports after review of unusual occurrence and adverse events and alerts appropriate regulatory body. Maintains documentation and reporting systems to ensure accurate and timely submission of required reports and regulatory filings. Oversees policies and procedure management for the network.
• Establishes and maintains proactive system for continual survey readiness with network and facility key stakeholders and department leader. Provides environmental assessments into the organizations strategic planning process regarding changes in regulatory environment, opportunities for improvement and exposure. Assess the impact of external regulations and cost containment efforts on Regulatory Compliance. Develops, plans and makes recommendations to minimize impact. Creates and promotes a clear departmental vision that supports the organization's strategic plan. Defines the department's strategic goals and objectives that support the day-to-day activities throughout the organization ensuring alignment with system accreditation department's strategic goal.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.