RN Director of Clinical Compliance

Humboldt Park Health•Chicago, IL

9d•$150,000 - $160,000

About The Position

Humboldt Park Health is seeking a full-time RN Director of Clinical Compliance to develop, implement, and sustain a comprehensive regulatory compliance and continuous survey readiness program across the hospital. Reporting to the Vice President of Quality & Risk Management, the Director serves as the hospital’s operational authority for regulatory compliance and accreditation readiness. The role ensures ongoing compliance with applicable federal, state, and accreditation standards, including those of The Joint Commission, CMS, IDPH, OSHA, and CDC. The Director works with executive leadership, physicians, nursing leaders, department directors, and frontline staff to embed survey readiness in daily operations. This highly visible leader spends most of their time in clinical and operational areas validating compliance, coaching leaders, conducting tracers, identifying risks, and promoting regulatory excellence. The role leads readiness programs, tracer and mock survey activities, enterprise-wide audits, policy governance, corrective action plans, environment-of-care compliance, regulatory communications and documentation, education, regulatory monitoring, and executive reporting. It also fosters accountability, collaboration, transparency, and continuous improvement throughout the organization.

Requirements

Bachelor’s degree in Nursing required.
5–7 years of experience in TJC accreditation, hospital operations, and clinical leadership.

Nice To Haves

Master’s degree preferred in Healthcare Administration, Nursing, Public Health, or a similar field.

Responsibilities

Lead the hospital’s continuous regulatory compliance and survey readiness program and develop strategic plans for ongoing compliance.
Interpret new and revised regulatory and accreditation standards and translate them into operational expectations.
Monitor compliance through rounding, audits, and performance indicators; identify risks and maintain readiness for unannounced surveys.
Coordinate readiness activities for The Joint Commission, CMS, IDPH, OSHA, CDC, emergency preparedness regulations, CMS quality programs, and other applicable agencies.
Lead interdisciplinary readiness committees, maintain survey documentation, validate corrective actions, conduct readiness rounds, prepare leaders for survey interviews, and ensure departments maintain compliance evidence.
Develop and oversee a Joint Commission methodology-based organizational tracer program, including patient, system, environment of care, medication management, infection prevention, high-risk process, and department-specific tracers.
Analyze tracer trends, coach staff during tracers, and develop follow-up action plans.
Lead annual hospital-wide and focused mock surveys, departmental assessments, leadership and medical staff interview preparation, surveyor simulations, feedback sessions, and final reports with corrective actions.
Develop and oversee an enterprise-wide regulatory audit program covering documentation, clinical practice, environment of care, medical records, medication management, infection prevention, emergency management, human resources, credentialing, and competency validation.
Ensure audit findings lead to measurable performance improvement.
Lead regulatory review and approval of organizational policies, policy gap analysis and standardization, alignment with current regulations, review-cycle monitoring, and policy governance.
Lead corrective action plans resulting from surveys, audits, mock surveys, complaint investigations, and citations; assign accountability, monitor completion, validate sustainability, collect evidence, prepare submissions, and report progress.
Collaborate with Facilities, Safety, Security, Clinical Engineering, and Environmental Services on environment of care, life safety, emergency management, utility management, fire safety, hazardous materials, and medical equipment compliance.
Participate in Environment of Care rounds and committee leadership.
Serve as operational liaison with regulatory agencies; coordinate survey logistics, document requests, inquiries, evidence submissions, correspondence, and leadership briefings.
Maintain an organized regulatory documentation system and ensure documentation is survey-ready.
Develop and deliver organization-wide education on regulatory standards, survey readiness, documentation expectations, leadership responsibilities, and staff preparedness.
Monitor regulatory and accreditation updates, assess their organizational impact, and coordinate implementation.
Report on readiness, audit findings, compliance trends, high-risk issues, corrective actions, survey preparation, regulatory updates, and key performance indicators.
Prepare presentations for executive leadership, committees, and the Board of Directors.
Foster a culture of continuous compliance and accountability; build relationships with organizational leaders, mentor department leaders, promote transparency and improvement, advise executive leadership, and lead multidisciplinary initiatives.
Adhere to downtime procedures and departmental policies, procedures, and objectives; perform job functions safely; model the hospital’s mission and values; pursue professional development; check hospital email daily; and perform other related duties as assigned.

Benefits

Medical, dental, and vision coverage for eligible employees, subject to applicable plan requirements.
Employer-paid life and AD&D insurance.
Flexible Spending Account options.
403(b) retirement plan with employer match, subject to eligibility requirements.
Paid Time Off, 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.