Division Director Regulatory Accreditation

Introduction

Last year alone, HCA Healthcare colleagues invested over 156,000 hours impacting our communities. As a Division Director of Regulatory Accreditation with Tristar Health, you can be a manager in an organization that is devoted to giving!

Benefits

Tristar Health offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Free counseling services and resources for emotional, physical and financial wellbeing
  
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
  
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
  
• Family support through fertility and family building benefits with Progyny and adoption assistance.
  
• Referral services for child, elder and pet care, home and auto repair, event planning and more
  
• Consumer discounts through Abenity and Consumer Discounts
  
• Retirement readiness, rollover assistance services and preferred banking partnerships
  
• Education assistance (tuition, student loan, certification support, dependent scholarships)
  
• Colleague recognition program
  
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
  
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Come join our team as a Division Director of Regulatory Accreditation. We care for our communities and employees! HCA Hope Fund in fourteen years reached a historic milestone: $50 million in help to our colleagues in need. Last year, HCA Healthcare and our colleagues donated $13.8 million dollars to charitable organizations. Apply today!

Job Summary and Qualifications

The Division Director of Regulatory Accreditation is responsible for administration and oversight of all activities concerning the achievement of continuous regulatory and accreditation readiness, regulatory response, quality excellence, and corporate safety compliance. The role provides oversight for matters including the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies and other external agencies for regulatory compliance.

This position works closely with the quality and safety areas, leadership, and department leaders within the Facilities, to support facilitation, development, implementation, and validation of systems to ensure compliance with external accrediting and regulatory bodies, while driving process improvement and safety across the division. The Director must be able to deploy to other divisions if necessary to support regulatory compliance.

What qualifications you will need:

• Bachelor’s Degree required
• Master’s or Doctoral Degree required
• 5-7 years of relevant consultative and/or leadership experience or equivalent combination of education and/or experience required
• Current licensure as a Registered Nurse (RN) or health professional in Tennessee or compact state required
• Certified Professional in Healthcare Quality (CPHQ) or Certification in Healthcare Quality Management (CHCQM) required within 12 months of employment start date
• Healthcare Accreditation Certification Program (HACP) required within 24 months of employment start date

What you will do in this role:

• Provide administration and oversight of all activities concerning the achievement of continuous regulatory and survey readiness.
• Ensure strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
• Direct strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations, along with safety policies and procedures and professional standards of the organization.
• Assist in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, and efficiency.
• Maintain knowledge of current accreditation and regulatory trends, guidance, standards, and requirements to ensure facility survey readiness and compliance and collaborate with the HCA Regulatory and Accreditation Team.
• Establish and maintain proactive system for continual survey readiness with division and facility key stakeholders and department leaders. Manage the division’s tracer process and audits, where appropriate. Recommend monitoring activities and determine effectiveness of interventions to meet desired outcomes.
• Develop and lead CMS, TJC, and state hospital licensure regulatory and quality compliance plan for the division hospitals and sites of care that fall under the hospital license.
• Oversee post-survey activities. Work with key stakeholders, including senior leadership team, to identify and address areas of non-compliance and assists in the development, submission, and implementation plans of correction. Oversee post-survey compliance activities to ensure successful implementation of process changes. Perform periodic re-evaluation and validation of results to ensure performance improvement is sustained.
• Develop and maintain strong, collaborative relationships with key stakeholders, including infection prevention, nursing, patient safety, facilities, medical staff services, etc.

HCA Healthcare has been named one of the World’s Most Ethical Companies by Ethisphere Institute for ten consecutive years (2010-2019). In 2019, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

Become a manager with an organization that invests in your career while giving to the community. We are seeking distinguished applicants for our Division Director of Regulatory Accreditation opening. Help HCA Healthcare create healthier tomorrows for patients and communities.

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.