Director of Regulatory Compliance

Job Description

Job Description

Humboldt Park Health is a safety-net hospital located in the Humboldt Park neighborhood of Chicago. We are dedicated to delivering high-quality, affordable, and compassionate healthcare services to the communities we serve. 

As a primary community healthcare provider, Humboldt Park Health focuses on treating and curing disease while promoting wellness through health education, prevention, and early intervention. Our 200-bed hospital provides inpatient acute care, emergency services, diagnostic services, and primary care. We also support the community through a full-service professional building, neighborhood clinics, and two mobile health units.

We are currently seeking a Full-Time Director of Regulatory Compliance to join our team!

 

Position Summary:

The Director of Regulatory Compliance is responsible for developing, implementing, and sustaining a comprehensive regulatory compliance and continuous survey readiness program across Humboldt Park Health. Reporting directly to the Vice President of Quality & Risk Management, this leader serves as the hospital's operational authority for regulatory compliance and accreditation readiness.

The Director ensures the organization maintains continuous compliance with all applicable federal, state, and accreditation standards, including but not limited to The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Illinois Department of Public Health (IDPH), Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), and other applicable regulatory agencies.

This position partners with executive leadership, physicians, nursing leadership, department directors, and frontline staff to foster a culture where survey readiness is integrated into daily operations rather than viewed as a periodic event. The Director is expected to be a highly visible leader who spends the majority of time in clinical and operational areas validating compliance, coaching leaders, conducting tracers, identifying risks, and ensuring regulatory excellence throughout the organization.

 

Essential Duties and Responsibilities:

Regulatory Compliance Leadership

• Lead the hospital's continuous regulatory compliance and survey readiness program.
• Develop strategic plans to ensure ongoing compliance with all applicable regulatory and accreditation standards.
• Serve as a subject matter expert regarding regulatory requirements.
• Interpret new and revised standards and translate them into operational expectations.
• Collaborate with executive leadership to establish regulatory priorities.
• Monitor organizational compliance through proactive rounding, audits, and performance indicators.
• Identify regulatory risks after they become survey findings.
• Maintain readiness for unannounced surveys at all times.

Continuous Survey Readiness

• Direct all organizational efforts related to continuous readiness for: The Joint Commission, CMS Conditions of Participation, Illinois Department of Public Health, OSHA, CDC guidance, Emergency Preparedness regulations, CMS Quality Programs, and other applicable accrediting or regulatory agencies.
• Responsibilities include coordinating organizational survey readiness activities, leading interdisciplinary readiness committees, maintaining survey documentation, validating corrective actions, conducting readiness rounds, preparing leadership for survey interviews, and ensuring departments maintain evidence of compliance.
• Organizational Tracer Program
  Develop and oversee a comprehensive tracer program utilizing Joint Commission methodology.
• Responsibilities include: Patient tracers, system tracers, environment of care tracers, medication management tracers, infection prevention tracers, high-risk process tracers, and department-specific tracers.
• Analyze trends and identify opportunities for improvement.
• Provide immediate coaching during tracers and develop follow-up action plans.

 

Mock Survey Leadership

• Lead comprehensive mock surveys throughout the organization.
• Responsibilities include: Annual hospital-wide mock surveys, focused mock surveys, departmental readiness assessments, leadership interview preparation, medical staff readiness, surveyor simulation exercises, immediate feedback sessions, and final reports with corrective actions

Regulatory Auditing

• Develop and oversee an enterprise-wide regulatory audit program including: documentation audits, clinical practice audits, environment of care audits, medical record audits, medication management audits, infection prevention audits, emergency management audits, human resources compliance audits, credentialing documentation reviews, and competency validation.
• Ensure audit findings lead to measurable performance improvement.

Policy Governance

• Lead the hospital's regulatory policy management process.
• Responsibilities include: regulatory review of all organizational policies, final regulatory approval prior to publication, policy gap analysis, standardization across departments, alignment with current regulations, monitoring policy review cycles, and maintaining policy governance structure.

Corrective Action Plan (CAP) Management

• Lead development and implementation of corrective action plans resulting from: Joint Commission findings, CMS surveys, IDPH surveys, internal audits, mock surveys, complaint investigations, and regulatory citations.
• Responsibilities include: developing action plans, assigning accountability, monitoring completion, validating sustainability, collecting evidence, preparing formal submissions, and reporting progress to executive leadership.

Environment of Care Compliance

• Collaborate with Facilities, Safety, Security, Clinical Engineering, and Environmental Services to ensure compliance with: environment of care standards, life safety code, emergency management, utility management, fire safety, hazardous materials, and medical equipment management.
• Participate in Environment of Care rounds and committee leadership.

 

Regulatory Communications

• Serve as the operational liaison with regulatory agencies.
• Responsibilities include: Coordinating survey logistics, managing document requests, responding to regulatory inquiries, coordinating evidence submissions, maintaining regulatory correspondence, preparing leadership briefings, and evidence management.
• Develop and maintain an organized regulatory documentation system including: survey evidence, policies, committee minutes, performance improvement data, competency records, audit results, regulatory correspondence, corrective action documentation, and ensure documentation is survey-ready at all times.

Regulatory Education

• Provide orientation and ongoing education programs.
• Develop and deliver organization-wide education related to: Joint Commission standards, CMS Conditions of Participation, IDPH regulations, OSHA requirements, survey readiness, documentation expectations, leadership responsibilities, and frontline staff preparedness.

Regulatory Monitoring

• Continuously monitor: Joint Commission updates, CMS regulations, IDPH updates, OSHA standards, CDC guidance, NFPA revisions, Federal Register publications, regulatory alerts, and accreditation newsletters
• Assess organizational impact and coordinate implementation.

Executive Reporting

• Provide routine reports to executive leadership regarding: organizational readiness, audit findings, compliance trends, high-risk issues, corrective action status, survey preparation, regulatory updates, and key performance indicators.
• Prepare presentations for Executive Leadership, Medical Executive Committee, Quality Committee, Safety Committee, Environment of Care Committee, and the Board of Directors.

Leadership Responsibilities

• Foster a culture of continuous compliance and accountability.
• Build collaborative relationships with leaders across the organization.
• Mentor department leaders regarding regulatory expectations.
• Promote transparency and continuous improvement.
• Serve as a trusted advisor to executive leadership.
• Lead multidisciplinary improvement initiatives.
• Support organizational strategic goals.

 

Other Responsibilities:

• Adheres to downtime procedures.
• Adheres to established departmental policies, procedures, and objectives.
• Performs both essential and non-essential job functions in a safe manner as identified by Humboldt Park Health.
• Demonstrates an understanding of and models the mission and core values of Humboldt Park Health.
• Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
• Checks hospital email daily.
• Performs other related duties as assigned.

Experience Required

• 5-7 years of experience in TJC accreditation, hospital operations, and clinical leadership

Educational Requirements:

• Bachelors in Nursing required;
• Masters preferred in Healthcare Administration, Nursing, Public Health, or similar.

 

Benefits

Benefits eligibility and offerings vary based on employment status and applicable plan requirements. Eligible employees may have access to:

• Medical, dental, and vision coverage
• Employer-paid life and AD&D insurance
• Flexible Spending Account (FSA) options
• 403(b) retirement plan with employer match, subject to eligibility requirements
• Paid Time Off (PTO), which may increase with years of service
• Employee discount at the Humboldt Park Health Wellness Center
• Education reimbursement, subject to eligibility requirements
• Employee wellness programs
• Additional voluntary benefits
• Opportunities for additional shifts, where applicable