Job Description

Purpose of Position and Scope of Responsibility

Provides systemwide leadership for regulatory planning, governmental approvals, licensure, Medicare and Medicaid enrollment, and accreditation support across Baptist’s hospitals, outpatient departments, physician practices, hospices, pharmacies, and affiliates. Serves as an agency liaison and advises leaders across executive, legal, compliance, clinical, operational, financial, quality, revenue cycle, and facilities functions on requirements, risks, and approval pathways.

Directs regulatory support for new services, acquisitions and changes of ownership, provider-based arrangements, facility construction and renovation, equipment changes, and other strategic initiatives. Ensures timely approvals, accurate records, and compliance with federal and state requirements in Tennessee, Mississippi, Arkansas, and other Baptist jurisdictions. Upholds Baptist's mission, vision, values, and principles through integrity, collaboration, accountability, patient safety, service, and regulatory excellence

Reporting Relation:

• Works for and in coordination with the Executive Vice President and Chief Legal Counsel regarding all essential functions related to regulatory planning, governmental approvals, licensure, provider enrollment, and accreditation support across Baptist.
• Has direct line accountability for direct reports.
• Serves as a liaison and provides guidance to Baptist leaders, designated project teams, and key stakeholders.

Essential Job Functions

1. Directs regulatory planning, facility and equipment licensure, certification, and governmental approvals across Baptist entities.
2. Develops coordinated regulatory strategies for complex, cross-entity initiatives; identifies approval dependencies, sequences required actions, and advises leadership on options, timing, and risks.
3. Leads Certificate of Need, determination-of-reviewability, exemption, Permit of Approval, and comparable processes, including applications, hearings, and required follow-up reports.
4. Analyzes changes in statutes, regulations, standards, and agency guidance with Legal and Compliance; assesses clinical, operational, financial, facility, and reimbursement implications and recommends actions to leadership.
5. Reviews new services, provider-based arrangements, facility projects, and equipment changes for licensure, enrollment, accreditation, life-safety, and operational-readiness requirements; coordinates with project and clinical stakeholders to address risks before implementation.
6. Oversees Medicare and Medicaid enrollment, revalidation, and updates related to locations, acquisitions, changes of ownership, and other organizational changes; maintains accurate information and authorized access in applicable systems.
7. Serves as a liaison to regulatory agencies, payers, and accrediting bodies to resolve applications, inspections, surveys, and approval issues.
8. Coordinates required regulatory submissions, renewals, surveys, and inspections; supports responses to findings, corrective actions, and fulfillment of approval conditions.
9. Maintains regulatory records and tracking tools; analyzes approval status, deadlines, conditions, and risks, and reports exceptions and recommended actions to leadership.
10. Educates leaders, project teams, other key stakeholders regarding changes in state and federal programs, enrollment processes, systems and requirements.
11. Supervises, coaches, and evaluates assigned Government Operations team members; sets priorities and holds the team accountable for timely, accurate work.
12. Manages assigned departmental and project budgets, filing fees, consultants, contracts, and external resources in accordance with Baptist approval requirements.
13. Performs other duties as assigned or directed.

Qualifications

• Bachelor's degree in healthcare administration, public administration, health policy, public health or related field; master's degree preferred .
• A minimum of seven years of progressively outcome-oriented experience in healthcare regulatory affairs, government operations, hospital administration, compliance, facility planning, accreditation, provider enrollment, or a related field required. Experience with multi-hospital or multi-state systems, facility activation or construction/renovation, or provider-based operations preferred.
• Certification or advanced training in healthcare compliance, healthcare quality, healthcare facilities, project management, accreditation, life safety, FGI, NFPA, or a related discipline preferred.
• Demonstrated experience with healthcare facility licensure and governmental approvals required, together with experience in at least two of the following: Medicare or Medicaid enrollment, Certificate of Need or comparable state approval processes, provider-based operations, healthcare facility planning, accreditation, acquisitions or changes of ownership, or complex regulatory project management.
• Advanced knowledge of healthcare regulatory planning, facility and equipment licensure, CMS requirements, Medicare certification, Medicaid enrollment, provider-based requirements, and Certificate of Need or comparable state approval processes.
• Working knowledge of PECOS, NPPES, PS&R, Medicare Administrative Contractors, state Medicaid systems, NCPDP, and related federal and state enrollment, identity, access, and reporting processes.
• Knowledge of healthcare facility design, construction, renovation, and occupancy requirements, including FGI guidance, Joint Commission standards, CMS Conditions of Participation, NFPA 99 and NFPA 101, infection-control considerations, and state plan-review and inspection processes.
• Ability to interpret statutes, regulations, standards, policies, technical documents, and evolving agency guidance in coordination with Legal and Compliance; assess clinical, operational, financial, facility, and reimbursement implications; and recommend practical solutions.
• Strong leadership, project management, analytical, writing, presentation, record-management, relationship-building, and problem-solving skills.
• Ability to manage multiple high-priority projects and deadlines across jurisdictions while maintaining accuracy, discretion, confidentiality, and professional judgment.
• Ability to collaborate effectively with executives, attorneys, clinicians, governmental officials, architects, engineers, consultants, contractors, and multidisciplinary teams.
• Travel required as needed to meet regulatory and operational requirements.