Director of Regulatory and Accreditation Services

Salary: $118,019.20 - $177,028.80
Full-time Days (No Weekends)

Description

Are you ready to manage in a new era as a Director of Regulatory and Accreditation Services where building a healthier tomorrow is more than a job? Our North Texas Division Office team is committed to partnership, innovation, legacy and improving more lives in more ways. Share your resume today.

North Texas Division Office, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Free counseling services and resources for emotional, physical and financial wellbeing
  
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
  
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
  
• Family support through fertility and family building benefits with Progyny and adoption assistance.
  
• Referral services for child, elder and pet care, home and auto repair, event planning and more
  
• Consumer discounts through Abenity and Consumer Discounts
  
• Retirement readiness, rollover assistance services and preferred banking partnerships
  
• Education assistance (tuition, student loan, certification support, dependent scholarships)
  
• Colleague recognition program
  
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
  
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Our teams are dedicated to improving human life. Each year about five percent of all U.S. hospital services happen at an HCA Healthcare facility. Be an impact as a Director of Regulatory and Accreditation Services where your passion for leading and creativity are valued? We want your knowledge and expertise!

The Division Director of Regulatory Compliance is responsible for administration and oversight of all activities concerning the achievement of continuous regulatory and accreditation readiness, regulatory response, quality excellence, and corporate safety compliance. The role provides oversight for matters including the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies and other external agencies for regulatory compliance.

This position works closely with the quality and safety areas, leadership, and department leaders within the Facilities, to support facilitation, development, implementation, and validation of systems to ensure compliance with external accrediting and regulatory bodies, while driving process improvement and safety across the division. The position must be able to deploy to other divisions if necessary to support regulatory compliance.

• Provides administration and oversight of all activities concerning the achievement of continuous regulatory and survey readiness. Ensures strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
• Directs strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations, along with safety policies and procedures and professional standards of the organization.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, and efficiency.
• Maintains knowledge of current accreditation and regulatory trends, guidance, standards, and requirements to ensure facility survey readiness and compliance and collaborates with the HCA Regulatory and Accreditation Team.
• Establishes and maintains proactive system for continual survey readiness with division and facility key stakeholders and department leaders. Manages the division’s tracer process and audits, where appropriate. Recommends monitoring activities and determines effectiveness of interventions to meet desired outcomes.
• Develops and leads CMS, TJC, and state hospital licensure regulatory and quality compliance plan for the division hospitals and sites of care that fall under the hospital license.

1. Monitors the survey readiness activities for compliance across the division.
2. Identifies opportunities and notifies appropriate leaders of necessary changes.
3. Serves as a division resource to address and resolve any accreditation questions or issues.
4. Coaches others in the development of accreditation improvement capabilities.
5. Identifies areas of improvement for the organization based on the information that flows through this position, working with others in the organization to encourage improvement.
6. Demonstrates knowledge and application of TJC standards and elements of performance, CMS Conditions of Participation, and state licensure requirements.
7. Oversees activities related to safety regulations, ensuring that all TJC, CMS, and state guidelines for the physical Environment of Care standards at the facility remain compliant. Service line accreditation is out of scope.
8. Analyzes, prepares and distributes accurate and timely reports on quality and survey monitoring efforts regarding regulatory requirements and standards.
9. Oversees post-survey activities. Works with key stakeholders, including senior leadership team, to identify and address areas of non-compliance and assists in the development, submission, and implementation plans of correction. Oversees post-survey compliance activities to ensure successful implementation of process changes. Performs periodic re-evaluation and validation of results to ensure performance improvement is sustained.

• Develops and maintains strong, collaborative relationships with key stakeholders, including infection prevention, nursing, patient safety, facilities, medical staff services, etc.
• Performs other duties as assigned.

What qualifications you will need:

Education & Experience:

• Master's or Doctoral degree required.
• 5-7+ years of relevant consultative and/or leadership experience or equivalent combination of education and/or experience required.

Licensure, Certifications, Training:

• Registered Nurse
• Certified Professional Healthcare Quality (CPHQ) must be obtained within 1 year of employment start date
• Healthcare Accreditation Cert Professional (HACP) must be obtained within 2 years of employment start date.

Medical City Healthcare strives to deliver excellence. We are committed to the care and improvement of human life. We provide the highest quality, cost-effective healthcare in the communities we serve. Medical City Healthcare is one of the North Texas region’s largest and most comprehensive healthcare providers. We have 16 hospitals, 5,000 physicians and more than 17,000 employees in Dallas-Fort Worth. Medical City Healthcare is the only healthcare system in North Texas with an adult and children’s hospital on the same campus. We are a part of HCA Healthcare. HCA Healthcare includes 185 hospitals in the United States and England. Medical City Healthcare has six hospitals that are Magnet® recognized by the American Nurses Credentialing Center Magnet Recognition Program®. We have been recognized by Texas Monthly as a Best Companies to Work for in Texas. HCA Healthcare has been named to LinkedIn’s 2021 Top Companies list of 50 best workplaces to grow your career.

HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"There is so much good to do in the world and so many different ways to do it."- Dr. Thomas Frist, Sr.

If this is the kind of dynamic growth opportunity that compels you, apply for the Director of Regulatory and Accreditation Services role. We are interviewing apply today!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.