Job Description

Job Summary

The Regional Director, Survey Readiness and Improvement is responsible for evaluating and enhancing the readiness of facilities for regulatory and accreditation surveys, including those conducted by The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), State Licensing, and other federal and state regulatory agencies. This role collaborates closely with corporate quality and compliance teams, facility leadership, and regional quality teams to address regulatory issues, support compliance, and implement corrective actions based on assessment findings. The Regional Director also provides guidance on regulatory standards and ensures that policies align with federal, state, and local healthcare regulations.

Essential Functions

Conducts mock surveys to evaluate the readiness of facilities for TJC, CMS, State Licensing, and other accrediting bodies, identifying gaps and providing feedback for corrective action. Provides comprehensive feedback to facility and regional leadership on survey findings, emerging trends, and specific regulatory or accreditation issues. Supports Regional leaders in planning and implementing follow-up actions based on mock survey results and regulatory findings. Collaborates with corporate and regional subject matter experts to ensure that up-to-date regulatory information, standards, and best practices are communicated and adhered to across facilities. Develops and standardizes educational resources and guidance on new or revised regulations, accreditation standards, and best practices for quality and compliance. Maintains a comprehensive database related to regulatory and accreditation topics to monitor compliance and trends across the region. Attends accreditation surveys as needed, staying informed on regulatory standards to support facilities effectively. Performs other duties as assigned. Complies with all policies and standards.

Qualifications

Bachelor's Degree in Healthcare Administration, Nursing, Public Health, or a related field required 5-7 years of experience in quality management, risk management, or compliance within a healthcare environment required Previous experience in survey preparation, regulatory compliance, and accreditation processes required Prior management experience required ***50% Travel required***

Knowledge, Skills and Abilities

Strong knowledge of healthcare regulations, accreditation standards, and survey processes (TJC, CMS, State Licensing). Excellent organizational and project management skills, with the ability to work across multiple facilities and manage diverse regulatory requirements. Proficient in data analysis, quality improvement methodologies, and compliance tracking. Strong verbal and written communication skills, with the ability to influence and educate staff on compliance and quality standards. Ability to work collaboratively with cross-functional teams and provide leadership on regulatory readiness.

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure required