Senior Accreditation and Regulatory Advisor

IU Health • Roanoke, IN

2d

About The Position

IU Health Fort Wayne is seeking an experienced Senior Accreditation & Regulatory Advisor to help prepare a new hospital for accreditation, regulatory compliance, and operational excellence. As part of the hospital’s opening team, the advisor will establish a culture of continuous readiness, support initial surveys and accreditations, and help advance IU Health’s journey toward Magnet Recognition.

The advisor plans, implements, directs, and facilitates initiatives supporting accreditation, regulatory compliance, survey readiness, and continuous quality improvement across IU Health Fort Wayne. Serving as a trusted advisor to operational, clinical, and executive leaders, the role provides expertise in accreditation and regulatory standards, leads organizational readiness efforts, coordinates regulatory surveys, and drives performance improvement to support patient care and organizational outcomes.

During the startup phase, the position focuses on preparing for accreditation and regulatory surveys, establishing compliance processes, and building a culture of continuous readiness. Following successful accreditation, the role continues to advance quality improvement, data-driven decision-making, and organizational excellence initiatives.

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.

Nice To Haves

• Certification through NAHQ is preferred.
• Master's degree preferred.
• Demonstrated experience preparing for, leading, or supporting accreditation and regulatory surveys.
• Strong communication, facilitation, relationship-building, and stakeholder influence skills.
• Ability to effectively work across all levels of the organization and build collaborative partnerships.

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.

Benefits

• Access to diverse opportunities for learning and development, including advanced clinical training, leadership development, promotion opportunities, and cross-training development.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior