Senior Accreditation and Regulatory Advisor
About The Position
The Senior Accreditation and Regulatory Advisor plans, implements, directs, and facilitates initiatives supporting accreditation, regulatory compliance, survey readiness, and continuous quality improvement across IU Health Fort Wayne. The advisor serves as a trusted resource to operational, clinical, and executive leaders by providing expertise in accreditation and regulatory standards, leading organizational readiness efforts, coordinating regulatory surveys, and driving performance improvement initiatives. During the hospital startup phase, the role focuses on preparing for accreditation and regulatory surveys, establishing compliance processes, and building a culture of continuous readiness. After successful accreditation, the advisor continues to advance quality improvement, data-driven decision-making, and organizational excellence initiatives. The position also supports IU Health Fort Wayne's journey toward Magnet Recognition and other healthcare excellence programs.
Requirements
- Bachelor's degree in Nursing, Healthcare Administration, Public Health, Health Informatics, Health Sciences, Project Management, or a related healthcare field.
- 7–10 years of experience in clinical operations and/or healthcare quality.
- Strong experience leading complex projects or systematic performance improvement.
- Strong communication, facilitation, relationship-building, and stakeholder influence skills.
- Ability to work effectively across all levels of the organization and build collaborative partnerships.
Nice To Haves
- Certification through NAHQ.
- Master's degree.
- Demonstrated experience preparing for, leading, or supporting accreditation and regulatory surveys.
Responsibilities
- Lead hospital-wide accreditation and regulatory readiness activities to ensure continuous compliance with applicable standards and requirements.
- Serve as the organization's subject matter expert for Joint Commission, state, and other regulatory and accreditation standards.
- Advise and educate leaders, providers, and team members on regulatory requirements, accreditation expectations, and survey preparedness.
- Coordinate and facilitate regulatory and accreditation surveys, including readiness assessments, survey planning, leadership coaching, document management, survey support, and post-survey follow-up.
- Develop, implement, and monitor corrective action plans resulting from survey findings and compliance reviews.
- Conduct multidisciplinary rounding, audits, and compliance assessments to evaluate adherence to organizational and regulatory standards.
- Research, interpret, and communicate evolving regulatory requirements and accreditation standards.
- Analyze quality and operational performance data to identify trends, risks, and opportunities for improvement.
- Lead complex quality, patient safety, and process improvement initiatives that support organizational goals and strategic priorities.
- Partner with leaders across departments to drive accountability, engagement, and sustainable performance improvement.
- Support organizational initiatives related to Magnet Recognition and healthcare excellence programs.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
