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System Director Regulatory Accreditation

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Job ID: 17919
Location: Vancouver, WA
Work Type: Full Time
Shift: Day
Shift Length: 8 Hours
FTE: 1.00
Benefit Eligibility: Full-time benefits

Job Description


PeaceHealth is seeking a System Director Regulatory Accreditation for a Full Time, 1.00 FTE, Day position.

Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.


Oversees the regulatory readiness program across the health system. Engages leadership at the System and local level to assure our organization is ready for regulatory surveys and meets regulatory requirements. Leads the regulatory team at the system and local level to develop, educate, plan, respond to, communicate, educate, implement and sustain all aspects of regulatory readiness relating to hospital and outpatient services accreditation associated with licensures across the system

Directs, controls and is accountable for integration of regulatory compliance of state, federal and accreditation standards, public reporting required by CMS, WA, OR and Alaska for PeaceHealth system wide. This includes but is not limited to PHMG, Acute Care Hospitals and Critical Access Hospitals, Home Health, Hospice and End Stage Renal Disease facilities. Develops long and short term regulatory and reporting strategies making it possible for PeaceHealth to be well positioned when new reporting requirements are announced. Communicates and advises Senior Leadership Group on strategies to prepare for upcoming publicly reported metrics. Integrates PeaceHealth business strategies, operational plans and directs implementation of these strategies. Manages the design, structure, development and planning issues within scope of direction. Directs the design, structure, development and planning for the teams of regulatory experts and data abstractors to maintain compliance and continue to receive Medicare/Medicaid payments for services and provide meaningful information on strategic initiatives and physician performance. Support system/network/community/medical group in the creation and implementation of policies, procedures, processes and programs designed to meet regulatory and accreditation requirements.


  • Responsible for overseeing the monitoring of regulatory, reporting and accreditation changes, and provide regular reports and updates to senior leadership as well as appropriate leadership/teams. Leads and communicates with appropriate administrative, clinical and operational leaders to develop and implement a strategy for regulatory and accreditation compliance, requirements.
  • Collaborates with system key stakeholders to assure integration of regulatory compliance in partnership with Organizational Integrity and Legal in PeaceHealth operations to continue to obtain payment from Medicare and Medicaid payors. Promotes operational compliance through the use of standard tools and approaches. Provides and educates to assure consistent interpretation and implementation of rules and regulations.
  • Manages team of regulatory experts to support PeaceHealth leadership in establishing compliant practices and maintain consistency in interpretation of rules. Responsible for the operational performance of assigned areas. Accountable for overall team management and project implementations.
  • Works with VP to develops annual regulatory readiness education program which is applicable across the health system. Works closely with System Clinical Education and local educational stakeholders to develop and implement the annual education plan. Utilize a variety of education methods, Team’s workshop calls, Mylearning, Regulatory Library etc.
  • Leads and mentors the Regulatory Readiness Team to support, advise, teach, direct and plan regulatory readiness activities and responses at the local level to assure local leadership expectations are being met. Hear issues and concerns of the team and facilitate resolution of those issues as they arise.
  • Works to assure a hospital specific regulatory tracer program is in place to assure proactive survey readiness. Develops annual plan and partners with unit and Department Managers to conduct internal tracers. Relies on resources from external entities as appropriate.
  • Work with System VP to transition the organization to the accreditation entity desired by PeaceHealth System leadership and the Board of Directors.
  • Responsible to transition PeaceHealth from reported metrics to electronic measurement controlled by CMS. Assuring that metrics which CMS will pull, are accurately captured and complete.
  • Proactively prepares for new CMS regulations and required reporting, positioning PeaceHealth to be prepared to have the best possible results.
  • Works with VP to monitor changes to regulator requirements that may impact hospital accreditation and develops monthly communication “Survey Alert” as appropriate.
  • Reviews and recommends appropriate accreditation, certification for PeaceHealth Senior Leadership to guide in approval of program development.
  • Leads other PeaceHealth leaders to assure standard approach to regulatory and accreditation issues/processes and ensures they are incorporated into strategic and operational plans.
  • Ensures appropriate tools and processes are available for tracking and trending of compliance data, identifying opportunities for improvement system wide.
  • Directs a team of subject matter expert clinical and technical staff to assure adherence to standard data definitions, data integrity practices, and data submission timelines to promote highly accurate, comparable, and actionable information.
  • Supports applicable regulatory and accreditation reporting requirements in a proactive manner. Proactively participates in the development of standard processes/systems designed to implement performance improvement, to support patient outcomes, required metrics and regulatory compliance across the organization.
  • Serve as member of the Clinical Excellence Leadership Team attending huddles, collaborating with other CE System Directors and supporting one another.
  • Accountable for overall team development, management and project implementations. Responsible for operational performance for areas of responsibility.
  • Performs other duties as assigned.


The following areas directly report to this position:

  • Regulatory and Accreditation Consultants
  • Regulatory and Accreditation Support Manager



  • Bachelor’s degree required.
  • Master’s degree preferred or a combination of education and professional experience that provides the caregiver with the requisite knowledge, skills and abilities to successfully perform the job. Willingness to work toward a master’s degree within 3 years of hire.
  • Some clinical experience desirable although not required.


  • Minimum of 7 years of related experience in a health care setting (hospital preferred).
  • Minimum of 5 years of management experience required.
  • Expert knowledge and skills in regulatory and accreditation standards obtained through a combination of education, training and experience.
  • Proven success in supporting healthcare institutions in meeting regulatory requirements and successfully reaching accreditation.
  • Advanced knowledge of state, federal, and accreditation requirements including but not limited to CMS Conditions of Participation for acute care and critical access hospitals, provider-based entities, ISO 9001, NIAHO, State healthcare rules and statutes, and state licensing requirements. General knowledge in other regulatory areas such as FDA and OSHA.
  • Strong knowledge and experience in quality improvement principles
  • Experience with managing complex programs and projects, specifically with a focus on regulatory and accreditation requirements and demonstrated successful completion of quality improvement projects with desired outcomes.
  • Experience and knowledge in use of administrative data quality, data specifications and statistical validity.
  • Experience using, teaching and applying quality management tools


  • HACP certified or willingness to complete in the first 12 months of hire.
  • Other accreditation certifications TBA as JCP is no longer available.


  • Strong leadership skills and ability to work independently to include work prioritizations.
  • Ability to serve as a team player and instill the importance of teamwork within the regulatory team.
  • Knowledge of Verge solutions and/or ability to learn system within the first 90 days of hire.
  • Ability to deliver financial results for areas of accountability.
  • Proven skills in team facilitation, project implementation, effective data interpretation, customer relations
  • Excellent verbal and written communication skills
  • Ability to prioritize and manage multiple projects in a highly matrixed and disbursed organization


  • May work remotely when there is little to no survey activity within the Networks.
  • Has some presence to work at PeaceHealth System when the System building is open and in-person meetings can be held..
  • Can shift work schedule in some cases quickly when there is an accreditation event at a hospital and the regulatory team needs assistance.
  • Attends face to face meetings annually and more often if needed with the System Directors.
  • Visits each network at least quarterly to demonstrate support for the team.


  • Work requires fairly light physical exertion from up to 65% of the time.
  • Ability to lift objects weighing 30 lbs. or less.
  • Work is performed under normal working conditions with adequate lighting and ventilation.
  • Job duties frequently require intense concentration and attention to detail (up to 65% of work time).

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.  

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.

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