Job Description

Position Title: Director, Accreditation & Regulatory Compliance

Department: Administration / Compliance Safety Sensitive: ☒ Yes ☐ No

Reports to: Chief Administrative Officer (CAO) Exempt Status: ☒ Yes ☐ No

The Director of Accreditation & Regulatory Compliance provides strategic leadership and organizational oversight for all accreditation, certification, and regulatory compliance activities in a DNV‑accredited hospital. This role ensures sustained compliance with DNV NIAHO® requirements, CMS Conditions of Participation, ISO 9001 Quality Management System standards, and applicable state and federal regulations, while fostering a culture of continuous readiness and risk‑based improvement.

The Director serves as the enterprise leader for accreditation strategy, survey readiness, and regulatory risk mitigation, coordinating across clinical, operational, and administrative departments.

About Kingman Regional Medical Center

Kingman Regional Medical Center (KRMC) is the largest employer, largest healthcare provider and the only remaining non-profit hospital in the Mohave County of Northwestern Arizona. We are a 235-bed, Level 4 trauma, multi-campus healthcare system. Our system includes over 270 physicians/allied health professionals and 1,900 employees and provides a full range of medical services ranging from essential primary care to complex surgery. Key clinical services include cardiology & cardiac rehab, oncology, emergency care, GI, general surgery, neurology, OB/GYN, orthopedics, physical & occupational therapy, pain management, thoracic surgery, urology, wound care, home health, and hospice care. KRMC was recently named a 4-star hospital by CMS, is the only hospital in Arizona to receive the Governor’s “Arizona Innovation Award” for proactive efforts to enhance healthcare in a rural community and has the distinction of being the state’s first rural teaching hospital offering physician residencies in family medicine and emergency medicine. We are hiring to meet the needs of our beautiful and growing community!

About Kingman, Arizona

Kingman, AZ is located along Historic Route 66, just 90 minutes south of Las Vegas and two hours North of Phoenix in the beautiful high desert of Mohave County. Our tranquil mid-sized community is relatively low stress; traffic is minimal and average commute times to work are under fifteen minutes. Kingman’s higher elevation keeps the sweltering desert summer temperatures away from the extremes (on average 10-15 degrees cooler than Phoenix and Las Vegas) with mild winter temperatures seeing an occasional dusting of snow. Located near the Colorado River that forms the western boundary of Mohave County with an estimated 1,000 miles of freshwater shoreline including Lake Havasu, Lake Mohave, and Lake Mead. Our climate is ideal for outdoor enthusiasts especially boating, kayaking, hiking, golf, and off-road adventures!

Kingman has one public school district, Kingman United School District (KUSD) for grades K-12 and one charter school, Kingman Academy of Learning for grades PreK-12. The Emmanual Christian Academy teaches students from kindergarten to 8th grade. Arizona Virtual Academic is a K-12 blended learning center. For post-secondary education, one of four main campuses of Mohave Community College (MCC) is in Kingman, as well as an extension campus of Northern Arizona University (NAU).

Health and Well-Being Benefits at KRMC

• Medical, Dental, Vision
• Wellness and Employee Assistance Program
• Employer Paid Group Life
• Short & Long-Term Disability
• Paid Time Off
• 403b Retirement Plan with Employer Contributions
• Employee Discounts
• Employee Referral Bonus Program
• Identity Theft Protection Program
• On-site daycare exclusive to our employees’ children from 6 months to school age! (fees apply)
• Discounted membership to on-site gym/wellness center with childcare

Career Growth and Development Benefits at KRMC

• Tuition Reimbursement for full-time employees
• Scholarships available
• Student Loan Forgiveness; As a not-for-profit organization, our employees who have qualified student loans, may be eligible for a Public Service Loan Forgiveness program

Key Responsibilities

• Strategic Leadership & Governance: Provide executive level oversight of accreditation and regulatory compliance programs, ensuring alignment with organizational priorities and enterprise risk management.; advise the CAO and senior leadership on accreditation risks, regulatory changes, and compliance trends; Serve as the organizational authority for DNV, CMS, ISO, and state regulatory interpretation.
• Accreditation & Survey Oversight: Direct all activities related to DNV NIAHO® accreditation, CMS validation surveys, ISO 9001 certification, and state licensure surveys; oversee enterprise‑wide survey readiness using a “ready every day” approach; provide executive oversight during on‑site surveys, including surveyor coordination, leadership briefings, issue resolution, and reporting requirements.
• Program Management & Continuous Readiness: Ensure the design, implementation, and sustainability of internal audit, mock survey, and tracer programs; monitor corrective action plans, risk trends, and sustainability of improvements; ensure accreditation requirements are embedded into operational workflows rather than treated as episodic activities
• Leadership of Accreditation & Audit Functions: provide direct leadership and performance oversight to the Accreditation Manager and Internal Auditor; ensure clear role delineation between strategic oversight (Director), program execution (Manager), and validation (Auditor); support staff competency development related to regulatory standards and survey preparedness.
• Policy, Standards & Regulatory Integration: oversee development, review, and governance of policies and procedures to ensure alignment with regulatory and accreditation standards; ensure document control and evidence management support survey readiness and traceability; collaborate with Nursing, Operational Clinical Departments, Quality, Risk, Safety, Infection Prevention, Facilities, IT, and Medical Staff leadership to ensure integrated compliance.
• Education & Organizational Engagement: ensure leaders and staff receive accurate, timely education regarding regulatory and accreditation requirements; promote organizational understanding of DNV’s management‑system‑based approach and risk‑based thinking.
• Performs other duties as assigned to support overall effectiveness of department and organization.

Required Qualifications

Education: Bachelor’s degree in healthcare administration, nursing, quality, or related field.

Experience: Minimum 7-10 years of progressive experience in hospital accreditation, regulatory compliance, or quality management. Demonstrated leadership experience in a DNV‑accredited hospital environment.

Knowledge, Skills, and Abilities

Strong working knowledge of:

• DNV NIAHO® standards
• CMS Conditions of Participation
• ISO 9001 Quality Management Systems
• Applicable NFPA Facilities Working Knowledge

Preferences

Education: Master’s degree in healthcare administration, nursing, public health, or related field.

Experience: Experience leading organizations through accreditation surveys with minimal findings.

Certification: Professional certifications such as CHOP, CHOP B, CPHQ, CPPS, CHC, or equivalent.

Knowledge, Skills, and Abilities:

• Skill in driving accountability across departments without direct operational control
• Experience integrating accreditation requirements into operational workflows
• Experience building internal audit, tracer, and monitoring programs that demonstrate system effectiveness

Special Position Requirements

Exposure Category III: Expected duties do not have potential for exposure to blood, body fluids or tissues.

Work Requirements

• Must be able to see and read reports, computer display terminals, and have manual dexterity to keypunch data via a keyboard.
• Hearing and verbal ability to interact with staff, managers, patients, and vendors.
• Must be able to stand or walk continuously Requires mobility to meet with management at their service area throughout the Health System.
• Must be able to sit for extended periods of time. May require extended periods of sedentary work and extended working hours to meet stated objectives.
• Able to demonstrate manual dexterity and mechanical ability.
• Must be able to lift 35 pounds

Date Staff Position Description Created / Revised: 03/09/2026