Director of Regulatory Compliance

Humboldt Park Health•Chicago, IL

20h•$140,000 - $150,000

About The Position

This role is responsible for leading hospital-wide regulatory compliance and continuous survey readiness. The Director will oversee readiness for various regulatory agencies, manage tracer programs, and lead mock surveys. Key responsibilities include auditing clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing. The position also involves overseeing regulatory policy governance, managing corrective action plans, ensuring environment of care compliance, and serving as a liaison with regulatory agencies. Additionally, the role provides organization-wide education on regulatory standards, monitors regulatory updates, reports compliance trends to executive leadership, and promotes a culture of compliance while mentoring leaders and supporting strategic improvement initiatives.

Requirements

Leadership in regulatory compliance and survey readiness.
Experience with Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies.
Development and oversight of tracer programs (patient, system, environment, medication, infection prevention, high-risk processes).
Experience leading mock surveys and departmental assessments.
Management of audits in clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing.
Oversight of regulatory policy governance.
Development and tracking of corrective action plans.
Ensuring compliance with environment of care standards (life safety, emergency management, utilities, fire safety, hazardous materials, equipment).
Liaison experience with regulatory agencies, including documentation and evidence submission.
Experience providing regulatory education.
Ability to track regulatory updates and coordinate implementation.
Experience reporting compliance trends and status to executive leadership.
Skills in promoting a culture of compliance, mentoring leaders, and supporting strategic initiatives.

Responsibilities

Lead hospital-wide regulatory compliance and continuous survey readiness.
Direct readiness for Joint Commission, CMS, IDPH, OSHA, CDC, and other regulatory agencies.
Develop and oversee patient, system, environment, medication, infection prevention, and high-risk process tracers.
Lead annual and focused mock surveys, departmental assessments, and leadership interview preparation.
Manage audits across clinical practice, documentation, environment of care, infection prevention, HR compliance, and credentialing.
Oversee regulatory policy review, approval, standardization, and compliance alignment.
Develop and track corrective action plans for survey findings, audits, complaints, and citations.
Ensure compliance with life safety, emergency management, utilities, fire safety, hazardous materials, and equipment standards.
Serve as liaison with regulatory agencies; manage documentation, evidence submissions, and survey logistics.
Provide organization-wide education on Joint Commission, CMS, IDPH, OSHA, and survey readiness.
Track regulatory updates and coordinate organizational implementation.
Report compliance trends, readiness status, audit findings, and CAP progress to executive leadership.
Promote a culture of compliance, mentor leaders, and support strategic improvement initiatives.