Accreditation and Regulatory Advisor

Indiana University Health; Tipton (IN); On-site; USD 85,000 - 120,000; Full time

Job summary

Indiana University Health is seeking an Accreditation & Regulatory Advisor (Critical Access Hospitals) to serve as a subject matter expert in accreditation, regulatory compliance, and survey readiness across IU Health's Critical Access Hospitals. This role supports education, consultation, and guidance to ensure safe, high-quality patient care.

Based at IU Health Frankfort Hospital with flexible home-base consideration and requires regular interfacility travel to support survey readiness,

Qualifications

• Bachelor's Degree required.
• 4–6 years of relevant regulatory experience.
• CPHQ or comparable certification endorsed by IU Health System Regulatory Affairs required within two years.
• Interfacility travel and in-state overnight stays required.
• Current Indiana license as a health care professional (RN, RT, Pharmacist or Rehab) is required.

Responsibilities

• Serves as primary accreditation and regulatory resource for assigned Critical Access Hospitals.
• Interprets accreditation standards, state and federal regulations, and compliance requirements for leaders.
• Plans and coordinates survey readiness activities (mock surveys, tracers, education sessions).
• Leads onsite accreditation surveys and coordinates activities before, during, and after survey events.
• Develops and monitors corrective action plans in response to findings and gaps.
• Prepares responses to regulatory agencies and accrediting bodies and follows up on actions.
• Evaluates services and workflows for regulatory compliance prior to implementation.
• Partners with leaders to identify improvement opportunities and address regulatory risks.
• Analyzes regulatory changes and communicates impacts and action plans to leadership.
• Provides regular readiness updates to facility and system leadership.
• Serves as liaison with Indiana Department of Health and accrediting organizations.
• Promotes continuous readiness through education, coaching, and process improvement.
• Participates in systemwide regulatory and accreditation initiatives.

Skills

Regulatory knowledge

Interfacility travel

Communication with leadership

Education

Bachelor's Degree

Job description

Overview

The Accreditation & Regulatory Advisor serves as a subject matter expert in accreditation, regulatory compliance, and survey readiness across IU Health's Critical Access Hospitals. This position is responsible for facilitating accreditation and regulatory compliance activities within assigned facilities while providing readiness support and consultation to additional IU Health facilities as needed.

Accreditation & Regulatory Advisor (Critical Access Hospitals)

Working collaboratively with operational leaders, clinical teams, and key stakeholders, the advisor promotes a culture of continuous survey readiness and regulatory compliance. The role provides education, consultation, and expert guidance regarding accreditation standards, regulatory requirements, and compliance best practices to support safe, high-quality patient care.

While the role is currently based out of IU Health Frankfort Hospital, flexibility may be considered regarding the home-base location based on the selected candidate's geographic location and organizational needs. Regular interfacility travel is required to support survey readiness, accreditation activities, and regulatory compliance initiatives.

Schedule

Monday-Friday, Day Shift

Key Responsibilities

• Serves as the primary accreditation and regulatory compliance resource for assigned Critical Access Hospitals and provides interfacility support throughout the IU Health system.
• Acts as a trusted advisor to leaders and stakeholders by interpreting accreditation standards, state and federal regulations, and organizational compliance requirements.
• Plans, coordinates, and facilitates survey readiness activities, including mock surveys, tracers, education sessions, and readiness assessments.
• Leads onsite accreditation and regulatory surveys, coordinating activities before, during, and after survey events to ensure successful execution.
• Develops, coordinates, and monitors comprehensive corrective action plans in response to survey findings, deficiencies, or identified compliance gaps.
• Prepares written responses to regulatory agencies and accrediting organizations and ensures timely completion of all required follow-up actions.
• Proactively evaluates new or revised services, programs, workflows, and physical spaces to assess regulatory and accreditation compliance requirements prior to implementation.
• Partners with operational and clinical leaders to identify opportunities for improvement and restore compliance when regulatory risks or deficiencies are identified.
• Analyzes regulatory changes and communicates impacts, recommendations, and action plans to leaders and stakeholders.
• Provides regular readiness and compliance updates to facility and system leadership, including assessment of compliance risks and mitigation strategies.
• Serves as the facility liaison for communications with the Indiana Department of Health and applicable accrediting organizations.
• Promotes a culture of continuous readiness through education, coaching, collaboration, and process improvement activities.
• Participates in systemwide regulatory and accreditation initiatives, special projects, and performance improvement efforts.

Qualifications

• Bachelor's Degree is required.
• Requires 4-6 years of relevant experience.
• CPHQ or other comparable healthcare regulatory certification endorsed by IU Health System Regulatory Affairs required within two years of employment.
• Interfacility travel for surveying and in-state overnight stays is required.
• Requires current state of Indiana license as a health care professional (e.g., Registered Nurse with an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license, Respiratory Therapist, Pharmacy or Rehabilitation license).

We are an equal opportunity employer. IU Health does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation.