Job Summary:

Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets. Implements system strategies and supports continuous survey readiness through operational execution. Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements. Leads corrective action planning, staff training, and policy implementation at facility level. Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission. Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction. Works closely with nursing, medical staff and other ...