Director of Regulatory Compliance

About the role

Essential Duties and Responsibilities Regulatory Compliance Leadership — Lead hospital‑wide regulatory compliance and continuous survey readiness. Survey Readiness Oversight — Direct readiness for Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies. Tracer Program Management — Develop and oversee patient, system, environment, medication, infection prevention, and high‑risk process tracers. Mock Survey Leadership — Lead annual and focused mock surveys, departmental assessments, and leadership interview preparation. Regulatory Auditing — Manage audits across clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing. Policy Governance — Oversee regulatory policy review, approval, standardization, and compliance alignment. Corrective Action Plan Management — Develop and track corrective action plans for survey findings, audits, complaints, and citations. Environment of Care Compliance — Ensure compliance with life safety, emergency management, utilities, fire safety, hazardous materials, and equipment standards. Regulatory Communications — Serve as liaison with regulatory agencies; manage documentation, evidence submissions, and survey logistics. Regulatory Education — Provide organization‑wide education on Joint Commission, CMS, IDPH, OSHA, and survey readiness. Regulatory Monitoring — Track regulatory updates and coordinate organizational implementation. Executive Reporting — Report compliance trends, readiness status, audit findings, and CAP progress to executive leadership. 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