Director of Regulatory Compliance

Essential Duties and Responsibilities

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  Regulatory Compliance Leadership — Lead hospital‑wide regulatory compliance and continuous survey readiness.

  
  


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  Survey Readiness Oversight — Direct readiness for Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies.

  
  


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  Tracer Program Management — Develop and oversee patient, system, environment, medication, infection prevention, and high‑risk process tracers.

  
  


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  Mock Survey Leadership — Lead annual and focused mock surveys, departmental assessments, and leadership interview preparation.

  
  


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  Regulatory Auditing — Manage audits across clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing.

  
  


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  Policy Governance — Oversee regulatory policy review, approval, standardization, and compliance alignment.

  
  


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  Corrective Action Plan Management — Develop and track corrective action plans for survey findings, audits, complaints, and citations.

  
  


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  Environment of Care Compliance — Ensure compliance with life safety, emergency management, utilities, fire safety, hazardous materials, and equipment standards.

  
  


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  Regulatory Communications — Serve as liaison with regulatory agencies; manage documentation, evidence submissions, and survey logistics.

  
  


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  Regulatory Education — Provide organization‑wide education on Joint Commission, CMS, IDPH, OSHA, and survey readiness.

  
  


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  Regulatory Monitoring — Track regulatory updates and coordinate organizational implementation.

  
  


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  Executive Reporting — Report compliance trends, readiness status, audit findings, and CAP progress to executive leadership.

  
  


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  Leadership Responsibilities — Promote a culture of compliance, mentor leaders, and support strategic improvement initiatives.   Minimum Acceptable Qualifications and Education: 

  
  


• 5-7 years of Experience Required


• Bachelors Degree Required