Market Director - Accreditation & Regulatory

REQUIRED EDUCATION: Registered Nurse with Master's Degree in Nursing, Healthcare Administration, Business Administration, or other relevant healthcare field plus five years of regulatory, accreditation, and performance improvement experience

MINIMUM EXPERIENCE: 7 years of progressive healthcare leadership experience with 5 years of experience leading hospital regulatory compliance, accreditation, quality, patient safety, or healthcare operations

PREFERRED EXPERIENCE\: Multi-facility, market, or system level leadership experience strongly preferred

REQUIRED CERTIFICATIONS/LICENSURE\: CPHQ, CPPS, or CPHRM certification within 12 months of hire

Facility Description:

DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure.

EEO Statement

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. 

Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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#LI-JG2

Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and  your community? At DMC Harper University Hospital, we’re  seeking an innovative and experienced healthcare  leader to drive excellence and inspire our team  towards exceptional patient outcomes and  operational success.

Benefit Statement: 

At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include\:  

• Medical, dental, vision, and life insurance

• 401(k) retirement savings plan with employer match

• Generous paid time off (PTO)  

• Career development and continuing education opportunities  

• Health savings accounts, healthcare & dependent flexible spending accounts

• Employee Assistance program, Employee discount program

• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.

Job Summary:

The Market Director, Regulatory & Accreditation provides strategic leadership and operational oversight for regulatory compliance, accreditation readiness, and survey management across a designated market of hospitals, ambulatory facilities, and affiliated healthcare entities. This leader partners with executive, clinical, operational, and physician leadership to ensure continuous compliance with federal, state, and accreditation requirements while fostering a culture of quality, patient safety, and operational excellence. Dotted line reporting structure to Corporate Sr. Director, Regulatory and Accreditation.

PRIMARY RESPONSIBILITIES 

Regulatory and Accreditation Compliance

• Direct market-wide regulatory compliance activities to ensure adherence to federal, state, and local regulations.
• Monitor changes in regulatory requirements and assess organizational impact.
• Develop and implement compliance strategies, policies, and procedures.
• Serve as a subject matter expert on regulatory and accreditation requirements, including CMS Conditions of Participation, state licensing regulations, and other healthcare regulations.
• Ensure timely and accurate completion of corrective action plans and evidence of standards compliance.
• Lead regulatory and accreditation readiness efforts for organizations
• Coordinate mock surveys, tracers, gap assessments, and continuous survey readiness activities.
• Oversee accreditation application, renewal, and maintenance processes.
• Lead regulatory and accreditation survey preparation, execution, and response activities.
• Coordinate survey command center operations during announced and unannounced surveys.
• Serve as primary market liaison for surveyors and regulatory agencies.
• Direct development and implementation of plans of correction and sustainable corrective actions.
• Collaborate closely with corporate regulatory and accreditation leadership

Organizational Integration

• Collaborate with quality, patient safety, risk management, infection prevention, and clinical operations leaders to address compliance risks.
• Analyze regulatory findings, trends, and organizational vulnerabilities to drive improvement initiatives.
• Support enterprise quality and patient safety objectives through proactive risk mitigation.

Leadership and Consultation

• Provide consultation and guidance to facility executives, department leaders, and governing boards.
• Lead and mentor regulatory and accreditation staff across the market.
• Facilitate education programs related to regulatory compliance and accreditation standards.
• Foster collaboration among hospitals, ambulatory facilities, and corporate departments.

Performance Improvement

• Develop market-wide compliance dashboards, metrics, and monitoring systems.
• Identify opportunities to improve regulatory performance and reduce organizational risk.
• Utilize data analytics to prioritize compliance activities and resource allocation.
• Lead special projects and strategic initiatives related to quality, safety, and compliance.

JOIN OUR TEAM

 QUALITY CARE DELIVERED BY COMPASSIONATE PEOPLE

We know it takes a special person to work in healthcare, and we are committed to providing our people with an enriching and rewarding environment. We deliver the resources, tools and support our employees need to serve our patients and customers in the best way possible — so we can create happier, healthier communities. 

COMMITTED TO DIVERSITY AND INCLUSION

At Tenet, we believe in a diverse and inclusive environment, one that is grounded in our dedication to the health and well-being of all people. Respecting, nurturing and encouraging diversity of thought, background and experience contribute to positive work environments that result in exceptional patient care. We embrace diversity because it's our culture, and because it's the right thing to do.