Market Director - Accreditation & Regulatory

DMC Group; Detroit (MI); Vor Ort; USD 150.000 - 210.000; Vollzeit

Benefits dieser Stelle

Medical insurance

401(k) with employer match

Generous PTO

Zusammenfassung

DMC Harper University Hospital in Detroit, Michigan seeks a Market Director, Regulatory & Accreditation to provide strategic leadership for regulatory compliance, accreditation readiness, and survey management across a network of hospitals and affiliated entities.

This role partners with executive, clinical, operational, and physician leaders to ensure ongoing compliance with CMS, state licensing, and accreditation standards while fostering a culture of quality, patient safety, and operational

Qualifikationen

• Registered Nurse license required.
• Master's degree in Nursing, Healthcare Administration, Business Administration, or related field required.
• CPHQ/CPPS/CPRM certification within 12 months of hire preferred or required within 12 months.

Aufgaben

• Lead market-wide regulatory compliance and accreditation readiness initiatives across hospitals and affiliated entities.
• Coordinate mock surveys, tracers, gap assessments and survey readiness activities.
• Develop and implement plans of correction and sustainable actions in response to survey findings.
• Collaborate with quality, patient safety, risk management, infection prevention, and clinical operations leadership to drive improvements.

Ausbildung

Registered Nurse (RN) license

Master's degree in Nursing or Healthcare Administration

Certification: CPHQ, CPPS, or CPHRM within 12 months of hire

Jobbeschreibung

Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and your community? At DMC Harper University Hospital, we’re seeking an innovative and experienced healthcare leader to drive excellence and inspire our team towards exceptional patient outcomes and operational success.

Benefit Statement

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.

Job Summary

The Market Director, Regulatory & Accreditation provides strategic leadership and operational oversight for regulatory compliance, accreditation readiness, and survey management across a designated market of hospitals, ambulatory facilities, and affiliated healthcare entities. This leader partners with executive, clinical, operational, and physician leadership to ensure continuous compliance with federal, state, and accreditation requirements while fostering a culture of quality, patient safety, and operational excellence. Dotted line reporting structure to Corporate Sr. Director, Regulatory and Accreditation.

Primary Responsibilities

Regulatory and Accreditation Compliance

• Direct market-wide regulatory compliance activities to ensure adherence to federal, state, and local regulations.
• Monitor changes in regulatory requirements and assess organizational impact.
• Develop and implement compliance strategies, policies, and procedures.
• Serve as a subject matter expert on regulatory and accreditation requirements, including CMS Conditions of Participation, state licensing regulations, and other healthcare regulations.
• Ensure timely and accurate completion of corrective action plans and evidence of standards compliance.
• Lead regulatory and accreditation readiness efforts for organizations
• Coordinate mock surveys, tracers, gap assessments, and continuous survey readiness activities.
• Oversee accreditation application, renewal, and maintenance processes.
• Lead regulatory and accreditation survey preparation, execution, and response activities.
• Coordinate survey command center operations during announced and unannounced surveys.
• Serve as primary market liaison for surveyors and regulatory agencies.
• Direct development and implementation of plans of correction and sustainable corrective actions.
• Collaborate closely with corporate regulatory and accreditation leadership

Organizational Integration

• Collaborate with quality, patient safety, risk management, infection prevention, and clinical operations leaders to address compliance risks.
• Analyze regulatory findings, trends, and organizational vulnerabilities to drive improvement initiatives.
• Support enterprise quality and patient safety objectives through proactive risk mitigation.

Leadership and Consultation

• Provide consultation and guidance to facility executives, department leaders, and governing boards.
• Lead and mentor regulatory and accreditation staff across the market.
• Facilitate education programs related to regulatory compliance and accreditation standards.
• Foster collaboration among hospitals, ambulatory facilities, and corporate departments.

Performance Improvement

• Develop market-wide compliance dashboards, metrics, and monitoring systems.
• Identify opportunities to improve regulatory performance and reduce organizational risk.
• Utilize data analytics to prioritize compliance activities and resource allocation.
• Lead special projects and strategic initiatives related to quality, safety, and compliance.

Qualifications

• REQUIRED EDUCATION: Registered Nurse with Master's Degree in Nursing, Healthcare Administration, Business Administration, or other relevant healthcare field plus five years of regulatory, accreditation, and performance improvement experience
• MINIMUM EXPERIENCE: 7 years of progressive healthcare leadership experience with 5 years of experience leading hospital regulatory compliance, accreditation, quality, patient safety, or healthcare operations
• PREFERRED EXPERIENCE: Multi-facility, market, or system level leadership experience strongly preferred
• REQUIRED CERTIFICATIONS/LICENSURE: CPHQ, CPPS, or CPHRM certification within 12 months of hire

Facility Description

DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure.

EEO Statement

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.

Job: Process Improvement
Primary Location: Detroit, Michigan
Facility: DMC Harper University/Hutzel Women's Hospital
Job Type: Full Time
Shift Type: Day