Senior Accreditation and Regulatory Specialist

Children's Nebraska•Omaha, NE

36d

About The Position

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.

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.
Leads mock surveys, tracers, and performance improvement efforts by planning and conducting internal mock surveys, tracers, and focused audits that simulate external survey expectations.
Coordinates and leads external survey activities by managing all aspects of accreditation and regulatory surveys, including applications, documentation, logistics, and day-of-survey operations.
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.