Compliance

• 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

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