Accreditation and Regulatory Compliance Specialist

Regions Hospital is seeking an Accreditation and Regulatory Compliance Specialist to support and advance a culture of continuous regulatory readiness and accreditation excellence. This position is responsible for leading the planning, implementation, and ongoing sustainment of accreditation and regulatory compliance initiatives that reduce organizational risk, strengthen patient and staff safety, and ensure compliance with applicable regulations, statutes, and accreditation standards. Working in partnership with the Manager of Accreditation and Regulatory Compliance, the specialist serves as a key resource to leaders, departments, and multidisciplinary teams across the organization.

Under the direction of the manager, the specialist will lead and participate in onsite and virtual accreditation surveys, regulatory investigations, and external agency reviews. This role collaborates closely with operational and clinical leaders to identify compliance risks, conduct assessments, develop corrective action plans, and implement sustainable improvement strategies. The specialist also coordinates activities that promote continuous readiness, regulatory awareness, and organizational compliance while supporting a culture of high reliability and excellence in patient care.

This position reports to the Manager of Accreditation and Regulatory Compliance and partners closely with accreditation and compliance leaders across both Regions Hospital and Methodist Hospital. While approximately 75% of the role's work will support Regions Hospital, the position will also collaborate with Methodist's Regulatory Compliance Program Manager to advance accreditation excellence, regulatory readiness, and organizational compliance across both organizations.

Required Qualifications:

• Bachelor’s degree and at least three (3) years of healthcare-related project management experience, or an equivalent combination of education and experience.
• Two (2) years of experience in accreditation, regulatory compliance, quality, risk management, patient safety, clinical operations, or a related healthcare function. Candidates with experience in ambulatory or outpatient healthcare settings are encouraged to apply.
• Working knowledge of accreditation and regulatory standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Minnesota Department of Health (MDH), and other applicable regulatory agencies.
• Familiarity with Occupational Safety and Health Administration (OSHA) regulations, building codes, and fire and life safety standards.
• Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
• Strong written, verbal, and interpersonal communication skills, with the ability to effectively communicate across all levels of an organization.
• Demonstrated critical thinking, analytical, problem-solving, and decision-making skills.
• Ability to manage multiple priorities, adapt to changing demands, and meet competing deadlines in a fast-paced environment.
• Strong organizational and project coordination skills, including the ability to schedule and manage complex meetings, calendars, and work plans.
• Ability to work both independently and collaboratively as part of a team.
• Demonstrated ability to build and maintain positive working relationships with frontline staff, leaders, physicians, and other stakeholders.
• Experience collecting, analyzing, interpreting, and presenting data through reports, presentations, and other communication tools.
• Knowledge of evidence-based practices related to patient safety, regulatory compliance, and healthcare quality improvement.
• Ability to conduct risk assessments, identify improvement opportunities, and support corrective action planning.
• Exceptional attention to detail and the ability to maintain accurate records and documentation.
• Ability to manage sensitive and confidential information with professionalism and discretion.

Preferred Qualifications:

• Masters Degree
• Certified Professional in Healthcare Quality (CPHQ) credential

Hours/Location:

• M-F; core business hours
• This hybrid positionrequires onsite work three days per week, typically Tuesday through Thursday,with additional onsitepresence asneeded to support business andoperational needs.

Compensation Range:

• $43.42 - $65.14 hourly
  • Compensation is based on the level and requirements of the role. Pay within our ranges may also be determined by education, experience, knowledge, skills, location, and abilities as well as internal equity. Hired candidates may be eligible to receive additional compensation based on role (e.g., shift differential, bonus, sales incentive, productivity pay, etc.).

Responsibilities:

Utilizes a systematic approach to improving regulatory readiness by proactively assessing the organization’s compliance status and developing action plans to mitigate areas of risk.

• Actively leading, planning and execution of initiatives, projects, and proactive risk reduction strategies to build a culture of high reliability across service lines and departments.
• Maintains and grows a robust process for on-going monitoring of upcoming changes or new accreditation or regulatory requirements. This includes partnering with leaders and subject matter experts to conduct gap analyses and risk assessments.
• Optimizes use of audits/tracers to monitor, report, and address the organization’s clinical and environmental risk areas.
• Conducts evaluation and surveillance of patient and clinical processes, systems, and environments within hospital departments to assess regulatory compliance. This includes leading and participating in Environmental Safety Rounds in patient care and non-patient care areas.
• Creates and maintains a comprehensive compliance scorecard/dashboard to visualize compliance metrics.
• Manages intra-cycle monitoring process.
• Analyzes compliance data to identify areas for improvement and determine level of risk to patient and staff safety.
• Manages and leads process improvement initiatives to mitigate areas of significant risk and engages leaders and subject matter experts in closing compliance gaps.
• Assesses, benchmarks and networks with hospitals locally and nationally to identify best practices.
• Maintains a broad base of project management, quality tools, and problem-solving methodologies.

Participates in the planning and facilitation of onsite and virtual accreditation surveys and regulatory complaint investigations.

• Responsible for pre-survey preparation, survey implementation, post-survey action planning, required follow-up, and compliance monitoring.
• Facilitates accreditation and regulatory surveys and investigations.
• Leads investigation and information-gathering for external agency requests. Formulates responses to external agency inquiries.
• Develops and modifies work standards and job aids for accreditation and regulatory surveys and associated processes.

Develops and presents regulatory readiness curriculum and training content.

• Creates timely communication organization-wide Huddle and Brief messaging and content to increase staff and leader understanding of regulatory standards and focus areas.
• Creates regulatory-focused education and guidance to convey information to target audiences which may include lunch and learn sessions and newsletters.

Plans, facilitates, and participates on various teams and committees as appropriate to support specific improvement efforts and continual regulatory readiness.

• Represents Accreditation and Regulatory Compliance department on a variety of hospital wide and system wide committees.
• Provides consultative services to policy owners and reviews document drafts for regulatory clarity, consistency, and compliance.