Field Medical Director, Oncology
Evolent
Hospital Regulatory and Accreditation Manager
INTEGRIS Health
full-time
Posted on:
Origin: • 🇺🇸 United States • Oklahoma
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Lead and coordinate a systemic approach for the hospital system’s regulatory compliance and accreditation programs, ensuring continuous readiness for surveys from accrediting bodies such as TJC, DNV, CMS, and State agencies
- Act as a strategic partner to system and facility leadership and staff by providing expert guidance, resources, and support to facilitate compliance with regulatory and accreditation requirements
- Foster a collaborative environment that encourages facilities to assume accountability for regulatory compliance and continuous quality improvement
- Provide operational oversight and coordination of survey activities in collaboration with facility leadership, ensuring thorough preparation, efficient execution, and effective post-survey follow-up
- Maintain and disseminate an accurate, comprehensive inventory of all applicable federal, state, and local regulatory and accreditation obligations across the hospital enterprise
- Monitor compliance through audits, tracers, and data analysis; identify gaps and support corrective action planning and execution
- Guide new departments, leaders, and facilities in meeting survey readiness and regulatory expectations
- Serve as a representative/expert on committees and task forces related to regulatory compliance and safety events
- Collaborate with policy governance stakeholders to support development, maintenance, and dissemination of policies aligned with regulatory and accreditation standards
- Partner with clinical and operational leaders to advise on policy development, revision, implementation, and alignment with regulatory expectations
- Support establishment of communication and dissemination plans and provide basic training and education on current regulatory standards, trends, and survey preparation
- Establish tracking systems, compile data, and prepare reports on compliance metrics, survey outcomes, corrective action progress, and regulatory submissions
- Manage accreditation-related portals, reference materials, and other regulatory tools and develop innovative solutions leveraging technology and data analytics
- Work setting generally at the corporate office with occasional overnight travel outside of the OKC metro area; may include extra or atypical hours and frequent changes of work assignment and interruptions
Requirements
- Five (5) years healthcare setting experience, acute care setting preferred
- Strong working knowledge of TJC or DNV, CMS, and relevant state-specific regulatory requirements
- Three (3) years professional development, consultation or leadership experience
- Bachelor’s degree in nursing or a healthcare related field
- Active and current clinical licensure
- Proficient in EHR and other common computer applications (i.e., Microsoft Word, Teams, Excel, PowerPoint and others)
- Must be able to communicate effectively in English (verbal/written)
- Master’s Degree (preferred)
- Certified Professional in Healthcare Quality (CPHQ) or similar (preferred; if not certified, will be required as part of a professional improvement plan)
- Certification, knowledge, or expertise with performance improvement/CQI methodologies (e.g., Continuous Improvement, Lean Six Sigma) (preferred)
- May require occasional overnight travel outside of the OKC metro area
- May include working extra hours or atypical work hours
- This position may have additional or varied physical demand and/or respiratory fit test requirements
