The Director of Regulatory Affairs is responsible for overseeing regulatory compliance initiatives to support patient safety and quality, ensuring adherence to Federal, State, and local regulations. This role focuses on managing accreditation and certification processes, including standards from The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and State/Local Departments of Health, in consultation with legal counsel as needed.
Interpret and operationalize regulatory requirements, including regulatory communication, staff education, and policy updates.
Coordinate virtual and onsite surveys by external regulatory and accreditation agencies, as well as mock surveys by consultants or internal teams.
Develop and implement corrective actions and monitoring plans to sustain compliance and improvements.
Collaborate on special projects as needed and serve as a resource for internal and external stakeholders.
Participate in organizational and health system committees to support regulatory and accreditation standards.
Master’s degree in a healthcare-related field preferred; nursing, public health, or a related clinical discipline is highly valued.
8-10 years of healthcare experience with knowledge of accreditation/certification processes and performance improvement methods.
Minimum of 2 years of direct management experience.
Experience in regulatory compliance, quality improvement, patient safety, risk management, or project management preferred.
Licensed or certified in a healthcare-related field.
Certified Professional in Healthcare Quality (CPHQ) preferred.
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