Director, DHIP - Accreditation & Regulatory

Duke Health Integrated Practice is an exceptional, multi-specialty physician practice encompassing 140 clinics across North Carolina. We attract and retain premier medical professionals with competitive compensation, benefits, and a nurturing work atmosphere that unites passion and purpose.

Learn more about us: https://dhip.dukehealth.org/about-us

JOB LOCATION

DHIP Administrative Offices RTP - 4825 Creekstone Dr

JOB SUMMARY

We are seeking a Director, DHIP - Accreditation & Regulatory to oversee accreditation and regulatory programs, ensuring entity-wide compliance with standards and improvement methodologies. This role collaborates with leaders and staff to maintain a unified understanding of regulatory requirements, support survey readiness, and standardize survey processes. Key goals include standards interpretation, compliance, education, communication, and effective survey operations.

JOB DUTIES AND RESPONSIBILITIES

• Plans and supports continuous compliance and readiness infrastructure; conducts ongoing monitoring, measurement and analysis of survey data and trends, communicates aggregate results and analyses; Partners with leadership to implement risk reduction and continuous compliance; Develops and maintains continual readiness accreditation tools, education and reference materials. Monitors for changes in federal and state regulations/standards and communicates changes to leadership and staff.
• Coordinates and participates in entity internal surveys using process audit tools and techniques to assess and evaluate ongoing survey readiness. Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment including Tracers and Mock Surveys.
• Co-manage with organizational leadership on-site accreditation, regulatory and certification surveys; Supports, leads and participates in entity pre-survey, on-site survey and post-survey activities for accreditation, regulatory and certification programs. Manage communications, agendas and logistics for on-site survey activities. 
• Develops toolkits, education and reference materials and provides educational opportunities and presentations. Ensures regulatory resources are up to date, such as Accreditation Manager Plus [AMP] software program, E-dition standards and links to other applicable guidelines/resources.
• Develops and implements a robust communication system that effectively informs all stakeholders about accreditation requirements, implications and changes.  Disseminates information clarifying regulatory and accreditation standards and organizes departmental and interdepartmental survey preparation and responses.
• Serves as contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals.
• Co-manage with entity operations leadership ongoing application requirements and corrective action plans; Ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation or certification.

JOB ELIGIBILITY REQUIREMENTS

• Work requires organizational, clinical, analytical, communication skills acquired through the completion of a bachelor’s degree program in Nursing, Business, or Healthcare Administration. Master’s degree preferred.
• A minimum of five (5) years working in accreditation, regulatory, patient safety or other applicable experience.

JOB HOURS

The schedule for this position is day shifts, Monday-Friday, with no weekends or holidays.

Some roles within our organization may encompass essential job functions requiring distinct physical and/or mental capabilities. Further details and accommodation requests will be addressed by individual hiring departments.

Duke Health Integrated Practice is dedicated to Equal Opportunity Employment, fostering a diverse workforce without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

We aspire to build a community grounded in collaboration, innovation, creativity, and belonging. Our shared achievements rely on a dynamic exchange of ideas, flourishing best when a multitude of perspectives, backgrounds, and experiences thrive. Upholding these values is a collective responsibility within our community.

This job description aims to outline representative responsibilities for this title, not an exhaustive account of specific duties. Employees may be assigned job-related tasks beyond those explicitly outlined here.