What are the responsibilities and job description for the Director of Regulatory Compliance position at Humboldt Park Health?
Essential Duties and Responsibilities
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Regulatory Compliance Leadership — Lead hospital‑wide regulatory compliance and continuous survey readiness.
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Survey Readiness Oversight — Direct readiness for Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies.
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Tracer Program Management — Develop and oversee patient, system, environment, medication, infection prevention, and high‑risk process tracers.
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Mock Survey Leadership — Lead annual and focused mock surveys, departmental assessments, and leadership interview preparation.
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Regulatory Auditing — Manage audits across clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing.
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Policy Governance — Oversee regulatory policy review, approval, standardization, and compliance alignment.
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Corrective Action Plan Management — Develop and track corrective action plans for survey findings, audits, complaints, and citations.
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Environment of Care Compliance — Ensure compliance with life safety, emergency management, utilities, fire safety, hazardous materials, and equipment standards.
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Regulatory Communications — Serve as liaison with regulatory agencies; manage documentation, evidence submissions, and survey logistics.
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Regulatory Education — Provide organization‑wide education on Joint Commission, CMS, IDPH, OSHA, and survey readiness.
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Regulatory Monitoring — Track regulatory updates and coordinate organizational implementation.
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Executive Reporting — Report compliance trends, readiness status, audit findings, and CAP progress to executive leadership.
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Leadership Responsibilities — Promote a culture of compliance, mentor leaders, and support strategic improvement initiatives. Minimum Acceptable Qualifications and Education:
- 5-7 years of Experience Required
- Bachelors Degree Required