Job Description

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve.

Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview
The Director of Accreditation & Regulatory Readiness provides strategic leadership, oversight, and daily management for all accreditation and regulatory compliance activities across the organization. This leader ensures continuous readiness with The Joint Commission (TJC), CMS Conditions of Participation, state and federal regulations, and all specialty accreditations—including hospital, home health, behavioral health, trauma, and transplant programs. This role actively models and advances ICARE Values and our People First Promise by embedding safety, respect, wellbeing, belonging, joy, and growth into the systems that govern regulatory readiness and high reliability. Through collaboration, coaching, and partnership with clinical and operational leaders, the Director ensures safe, high-quality care for children and families.

Essential Functions

Accreditation Leadership & Oversight

• Serves as the enterprise subject matter expert for all TJC and CMS regulations and standards across accredited programs.
• Leads to continuous readiness through systematic evaluation of compliance, identification of risks, and partnership with leaders to implement sustainable corrective actions.
• Develops and oversees a comprehensive accreditation readiness framework, including tracers, mock surveys, environmental rounds, documentation audits, and process reviews.
• Collaborates with Medical Staff, nursing, ancillary services, and operational leaders to deliver training, updates, and coaching related to accreditation and regulatory expectations.
• Recommends and assists with the development of new or revised workflows, policies, and processes to maintain compliance with laws, regulations, and accreditation standards.
• Ensures timely dissemination and implementation of new or updated regulatory requirements.
• Leads and coordinates all survey activities, serving as primary onsite contact for accrediting and regulatory agencies.
• Communicates readiness status, risks, observations, and action plans with transparency and clarity.

Regulatory Performance & National Performance Improvement Goals

• Oversee organizational compliance with Joint Commission National Performance Improvement Goals; collaborates with Quality, Safety, and operational leaders to evaluate performance.
• Reviews compliance trends, identifies opportunities for improvement, and develops action plans with accountable owners.
• Ensures accurate documentation, reporting, and follow-up related to regulatory performance.

Education Qualifications

• Bachelor's degree in Healthcare Quality Management, Nursing, Health Administration, or related field required
• Master's degree preferred

Experience Qualifications

• Minimum 5 years' experience in healthcare leadership with responsibility for accreditation, regulatory compliance, quality, or patient safety required
• Pediatric healthcare experience preferred

Skills and Abilities

• Demonstrates flexibility and the ability to lead through change
• Strong strategic influence skills with the ability to engage leaders and teams
• Excellent written, verbal, and presentation communication skills
• Skilled at facilitating collaboration, team building, and cross-functional engagement
• Project management expertise with ability to manage multiple priorities
• Strong analytic and problem-solving skills
• Ability to interact professionally with physicians, staff, families, and external partners
• Knowledge of systems theory and its application to process design and evaluation

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