Director, Regulatory Compliance and Accreditation Services

Who we are:

At Lifepoint Health, we provide quality healthcare to rural communities. As a valued member of our team, you will be an integral part of a group working together to elevate Lifepoint's healthcare delivery network. Our network includes 60+ community hospitals, 60+ rehabilitation/behavioral health hospitals, and 250 additional sites of care across the United States. As an organization, we are dedicated to serving communities nationwide by providing exceptional care. We believe in the power of our talented teams and strive to create environments where employees find purpose and fulfillment.

What you’ll do:

As a Director, Regulatory Compliance and Accreditation Services, you will provide guidance and support, education, training and mentorship for CMS Conditions of Participation, accreditation, and survey readiness activities relative to clinical quality, patient safety, infection prevention and control, organization performance and compliance with law, regulation and accreditation standards.   The Director closely collaborates with the Hospital Operations – Clinical and Quality Teams and others in the Health Support Center office and at the local facility level in advancing high- quality, safety and clinical processes, regulatory and accreditation compliance to achieve positive patient outcomes and serve in the capacity of coach and mentor.

Responsibilities:

• Participates in Survey Readiness Assessments (SRAs) throughout the LifePoint System to assess and evaluate an organization actual performance of functions and processes aimed at continuously improving patient outcomes and their ability to provide safe, high-quality care.
• Provides resource for accreditation, CMS Conditions of Participation, performance improvement, patient safety, infection control processes.
• Applies systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance with applicable standards and functionality of care delivery systems.
• Engages health care organization staff in interactive dialogues on standards-based issues in health care to assess compliance and to identify opportunities for improving compliance.
• Prepares SRA reports that effectively link individual standards deficiencies with potential systems vulnerabilities and related organization risk points.
• Effectively communicates survey finding information to organization and division leadership in a constructive and collegial style.
• Works in concert with VP and AVPs to ensure that HSC and hospital leaders and managers remain current on TJC/CMS and other accreditation standards and requirements.
• Works with key stakeholders to evaluate performance and outcome data to identify potential improvement opportunities and/or evaluate the effectiveness of improvement initiatives.
• Supports organizations in the development, review and implementation of improvement plans for accreditation and/or regulatory.
• Based on data analytics identities, develops, and disseminates helpful resources and best practices for regulatory and accreditation compliance.
• Provides consultative and educational support to hospitals relative to clinical quality, patient safety, infection prevention and control, and regulatory/accreditation compliance.
• Acts as a liaison with other HSC departments concerning regulatory, accreditation, patient safety, infection prevention and control and quality improvement strategies.
• Prepares and presents pertinent educational programs using adult learning principles for identified improvement needs.
• Provides onboarding, mentors, coaches, and supports to Lifepoint Health Quality Directors.
• Demonstrates effective organizational, oral, and written communication skills, problem solving, program development, computer skills, strong leadership and team building skills.  
• Participates in other Hospital Support Center activities as assigned by VP Regulatory Compliance and Accreditation.

What you’ll need:

Education:

• RN with a master's degree in healthcare administration/management or a related field.  PharmD will be considered for the position.
• Current professional license in discipline required at time of hire and must be maintained.
• CPHQ and/or CPPS preferred. 

Experience: Minimum of 7 years of healthcare experience with at least 5 of those years served in a managerial/supervisory or leadership role. 

Why choose us:

As a team member of the Health Support Center, our goal is to support those that are in our facilities who are interfacing and providing care to our patients and community members. Our focus is to attract, retain, and empower a diverse and determined workforce. Our mission statement is at the heart of who we are and what we do: “Making Communities Healthier.” In this shared mission, we believe that our collective efforts will shape a healthier future for the communities we serve.

Benefits: We offer an excellent total compensation package, including a competitive salary and benefits. Some of our benefits include 401k, flexible PTO, generous Employee illness benefit (EIB), medical, dental, vision, tuition reimbursement, and an Employee Assistance Program. We believe that happy, healthy people have a passionate engagement with life and work and have designed our package to enhance your wellbeing.