Accreditation & Regulatory Leader — Critical Access

IU Health; Monticello (IN); On-site; USD 85,000 - 120,000; Full time

Job summary

IU Health seeks an Accreditation & Regulatory Advisor to ensure survey readiness and regulatory compliance across its Critical Access Hospitals. The role partners with clinical leaders, coordinates mock surveys, tracers, and education sessions, and leads onsite surveys to ensure robust accreditation outcomes.

The position requires a Bachelor's degree, 4-6 years of relevant experience, and a CPHQ or equivalent certification within two years, with interfacility travel and Indiana licensure.

Qualifications

• Bachelor's Degree is required.
• Requires 4-6 years of relevant experience.
• CPHQ or other 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 Indiana license as a health care professional (e.g., RN, RT, Pharmacy or Rehab).

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 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 spaces to assess regulatory and accreditation compliance prior to implementation.
• Partners with leaders to identify opportunities for improvement and restore compliance when risks are identified.
• Analyzes regulatory changes and communicates impacts and action plans to leaders.
• Provides regular readiness 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 accrediting organizations.

Skills

Regulatory knowledge

Survey readiness

Interfacility travel

Education

Bachelor's degree

Job description

IU Health seeks an Accreditation & Regulatory Advisor to ensure survey readiness and regulatory compliance across its Critical Access Hospitals. The role partners with clinical leaders, coordinates mock surveys, tracers, and education sessions, and leads onsite surveys to ensure robust accreditation outcomes.

The position requires a Bachelor's degree, 4-6 years of relevant experience, and a CPHQ or equivalent certification within two years, with interfacility travel and Indiana licensure.