Senior Accreditation and Regulatory Specialist

Children's Hospital & Medical Center•Omaha, NE

29d

About The Position

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities. A Brief Overview The Sr Accreditation and Regulatory Specialist supports enterprise-wide survey readiness and regulatory compliance across Children's Nebraska, including the hospital, specialty programs, behavioral health, home health, and ambulatory sites. The role partners with senior leaders and program directors to ensure continuous readiness for The Joint Commission, CMS, state licensure, and specialty program regulators. As a subject-matter expert, this role interprets complex standards, identifies system-level risks, and leads initiatives that strengthen compliance and elevate performance. They guide programs through the full accreditation lifecycle—preparation, survey coordination, and post-survey follow-up—while ensuring consistency, accountability, and alignment with organizational priorities. Using strong change-management skills, the role advances a culture of everyday readiness and integrates regulatory excellence into daily operations across all settings. Essential Functions The Sr Accreditation and Regulatory Specialist serves as a system-wide leader for continuous survey readiness, maintaining expert knowledge of accreditation and regulatory requirements across all applicable programs, including the Hospital, Behavioral Health, Home Health, Dialysis, and Heart Transplant. The role partners with senior leaders and program directors to translate complex standards into operational practice and ensure readiness is integrated into daily workflows. They lead organizational initiatives to sustain compliance with The Joint Commission, CMS, state licensure, and specialty program standards, recommending systemwide improvements and best practices. The Sr Accreditation and Regulatory Specialist designs and deploys RLDatix Audits & Standards (A&S) rounding tools, dashboards, and audit mechanisms to support consistent monitoring and proactive compliance improvement. They review audit findings within RLDatix A&S, collaborate with local leaders to provide coaching, confirm timely corrective actions, and ensure sustained resolution of identified gaps in support of high-reliability performance. Additionally, the role acts as a trusted advisor to senior leadership on emerging regulatory trends, risks, and anticipated requirements that may influence strategic planning and service growth. Drives education, communication, and change management by developing and delivering strategies that strengthen organizational understanding of accreditation and regulatory standards. The role guides teams through change management processes that promote accountability, ownership, and cultural transformation related to regulatory readiness. It mentors leaders and front line staff during walk-rounds, providing real-time coaching and reinforcing expected practices. Additionally, the Strategy Partner leads the maintenance and enhancement of accreditation and regulatory resources on internal platforms, ensuring content remains accurate, accessible, engaging, and aligned with current standards. Leads mock surveys, tracers, and performance improvement efforts by planning and conducting internal mock surveys, tracers, and focused audits that simulate external survey expectations. The role engages interdisciplinary teams in tracer methodology to uncover gaps, validate corrective actions, and sustain improvements. It prepares high-quality executive reports summarizing readiness findings, trends, and organizational themes, and partners with leaders to prioritize action plans. The Strategy Partner also leads or participates in targeted quality improvement initiatives related to accreditation or regulatory findings, ensuring corrective actions are measurable, evidence based, and sustainable. Additionally, the role monitors intracycle performance metrics, analyzes patterns, and drives targeted interventions to close compliance gaps ahead of upcoming survey cycles. Coordinates and leads external survey activities by managing all aspects of accreditation and regulatory surveys, including applications, documentation, logistics, and day-of-survey operations. The role leads Command Center operations during surveys, organizing escort and scribe assignments and ensuring coordinated execution and follow-up. It provides daily briefings throughout the survey process and leads post-survey communication, documentation, and response activities. The Strategy Partner also collaborates with consulting agencies and external partners to plan, facilitate, and evaluate readiness reviews and consultative surveys. Supports specialty program accreditation and growth by partnering with clinical and administrative leaders to guide new and existing programs such as Behavioral Health, Dialysis, Heart Transplant, and future services through their accreditation lifecycle. The role supports programs preparing for initial and ongoing certifications by interpreting standards, developing required documentation, and validating readiness. It also integrates new program accreditation requirements into system policies, procedures, monitoring frameworks, and the overall readiness infrastructure.

Requirements

Bachelor's Degree in Healthcare Administration, Nursing, Public Health, Business, or related field Required
Minimum 3 years' experience in healthcare accreditation, regulatory readiness, quality improvement, patient safety, compliance, or a related area, including experience interpreting and applying standards from The Joint Commission, CMS, and state regulatory agencies. Required
Demonstrated proficiency in project management, data analysis, and facilitation of multidisciplinary teams Required
Expert knowledge of accrediting and regulatory standards, including The Joint Commission (Hospital and Behavioral Health), CMS Conditions of Participation, state licensure requirements, and specialty program standards such as Transplant, Dialysis, and Behavioral Health, with the ability to interpret legal, regulatory, and policy documents and apply them operationally.
Strong capability in quality, safety, and performance improvement methodologies (PDSA, RCA, FMEA, LEAN) and in reviewing clinical documentation and medical records for compliance with accreditation and regulatory expectations.
Demonstrated ability to lead without authority, influence behavior change, mentor leaders and frontline staff, and guide interdisciplinary teams through readiness, improvement efforts, mock surveys, tracers, and education.
Advanced project management, organizational, and analytical skills, including managing complex systemwide initiatives, interpreting audit data and performance metrics, identifying trends, and translating insights into actionable improvement plans.
Exceptional verbal and written communication skills, with the ability to translate complex regulatory concepts for diverse audiences and maintain professionalism, confidentiality, and sound judgment in high-pressure or ambiguous situations.
High proficiency with Microsoft Office Suite and familiarity with accreditation management or regulatory tracking platforms, with strong attention to detail, accuracy, and documentation rigor.
Ability to work independently in a dynamic environment, manage multiple competing priorities and regulatory timelines, maintain resilience during unannounced surveys, and build effective relationships with senior leaders, physicians, frontline staff, and external partners.
If filled by a nurse - RN - Registered Nurse - State Licensure and/or Compact State Licensure - current and valid Nebraska RN license/RN compact license. Required
Health Services\BCLS - Basic Life Support - If filled by a nurse - current and valid Basic Life Support (BLS) through the American Heart Association Required
HACP - Healthcare Accreditation Certification Program - or equivalent within 3 years of hire. Required

Nice To Haves

Master's Degree in Healthcare Administration, Nursing, Public Health, Business, or related field Preferred
5 years or more experience in accreditation, regulatory readiness, quality, or healthcare compliance within a hospital or health system, including work with specialty program accreditation such as Transplant, Dialysis, or Behavioral Health, and leading improvement initiatives or corrective action plans resulting from survey findings or regulatory gaps Preferred

Responsibilities

Serves as a system-wide leader for continuous survey readiness, maintaining expert knowledge of accreditation and regulatory requirements across all applicable programs, including the Hospital, Behavioral Health, Home Health, Dialysis, and Heart Transplant.
Partners with senior leaders and program directors to translate complex standards into operational practice and ensure readiness is integrated into daily workflows.
Leads organizational initiatives to sustain compliance with The Joint Commission, CMS, state licensure, and specialty program standards, recommending systemwide improvements and best practices.
Designs and deploys RLDatix Audits & Standards (A&S) rounding tools, dashboards, and audit mechanisms to support consistent monitoring and proactive compliance improvement.
Reviews audit findings within RLDatix A&S, collaborate with local leaders to provide coaching, confirm timely corrective actions, and ensure sustained resolution of identified gaps in support of high-reliability performance.
Acts as a trusted advisor to senior leadership on emerging regulatory trends, risks, and anticipated requirements that may influence strategic planning and service growth.
Drives education, communication, and change management by developing and delivering strategies that strengthen organizational understanding of accreditation and regulatory standards.
Guides teams through change management processes that promote accountability, ownership, and cultural transformation related to regulatory readiness.
Mentors leaders and front line staff during walk-rounds, providing real-time coaching and reinforcing expected practices.
Leads the maintenance and enhancement of accreditation and regulatory resources on internal platforms, ensuring content remains accurate, accessible, engaging, and aligned with current standards.
Leads mock surveys, tracers, and performance improvement efforts by planning and conducting internal mock surveys, tracers, and focused audits that simulate external survey expectations.
Engages interdisciplinary teams in tracer methodology to uncover gaps, validate corrective actions, and sustain improvements.
Prepares high-quality executive reports summarizing readiness findings, trends, and organizational themes, and partners with leaders to prioritize action plans.
Leads or participates in targeted quality improvement initiatives related to accreditation or regulatory findings, ensuring corrective actions are measurable, evidence based, and sustainable.
Monitors intracycle performance metrics, analyzes patterns, and drives targeted interventions to close compliance gaps ahead of upcoming survey cycles.
Coordinates and leads external survey activities by managing all aspects of accreditation and regulatory surveys, including applications, documentation, logistics, and day-of-survey operations.
Leads Command Center operations during surveys, organizing escort and scribe assignments and ensuring coordinated execution and follow-up.
Provides daily briefings throughout the survey process and leads post-survey communication, documentation, and response activities.
Collaborates with consulting agencies and external partners to plan, facilitate, and evaluate readiness reviews and consultative surveys.
Supports specialty program accreditation and growth by partnering with clinical and administrative leaders to guide new and existing programs such as Behavioral Health, Dialysis, Heart Transplant, and future services through their accreditation lifecycle.
Supports programs preparing for initial and ongoing certifications by interpreting standards, developing required documentation, and validating readiness.
Integrates new program accreditation requirements into system policies, procedures, monitoring frameworks, and the overall readiness infrastructure.