RN Regulatory Advisor - Performance Improvement

The successful candidate:

** This position is open only to local candidates due to onsite requirements

Location: Zion, IL.

Schedule

• Mon - Fri, Day shift (40 hrs per week)

Job Summary

The Regulatory and Accreditation Advisor provides strategic leadership, expert guidance, and independent oversight for regulatory compliance and accreditation activities across the organization. This role interprets and applies federal and state regulatory requirements, national accreditation standards, and internal policies to assess compliance risk, advise leaders, establish priorities, and recommend strategies that support survey readiness, quality outcomes, and safe patient care.

This position leads and facilitates performance improvement and regulatory readiness initiatives from scope definition through implementation, including project planning, timeline development, stakeholder engagement, outcome evaluation, and documentation of results to support compliance with accreditation and quality standards.

The Regulatory and Accreditation Advisor independently manages regulatory and quality improvement projects from concept through implementation and participates in more complex enterprise initiatives. This role develops and recommends communication strategies, prepares internal and external reports by analyzing and summarizing data and information for leadership, and maintains project documentation necessary to support compliance, decision-making, and sustained performance improvement.

They partner with clinical, administrative, legal, and quality leaders to interpret changing regulations, evaluate organizational practices, guide readiness for surveys and inspections, and recommend corrective actions and system improvements. The role supports enterprise-wide initiatives and serves as a regulatory and accreditation resource to leadership, departments, clinics, physicians, and administration.

This position exercises discretion and independent judgment in matters of significance, including interpreting regulatory and accreditation requirements, assessing compliance risk, advising leaders, determining implementation priorities, and recommending strategies to maintain continuous survey readiness and support quality and patient safety outcomes. Provides cross-coverage for Quality team functions as needed.

Position Qualifications

Minimum Education

• Bachelors of Science degree in Nursing

License

• Illinois State RN License

Minimum Experience

• Minimum of three (3) years of experience in clinical nursing and/or quality, risk, or regulatory functions

Preferred Qualifications

Certification

• Healthcare Accreditation Certification Program (HACP)

Experience

• Thorough knowledge of Joint Commission standards, Illinois Department of Public Health (IDPH), CMS Conditions of Participation, and other regulatory agencies

Skills & Abilities

• Demonstrates sensitivity to patient care and patient privacy
• Strong interpersonal skills that promote trust and collaboration
• Professional demeanor that fosters a positive organizational image
• Cultural sensitivity and awareness of diversity and inclusion
• Excellent verbal, written, organizational, and presentation skills
• Proficiency with computer applications and software tools
• Data analysis and data visualization skills
• Ability to build engagement and enthusiasm for quality and compliance initiatives

City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location.