Join our Talent Network
Skip to main content
   Current UPHS employees must apply HERE

Director of Regulatory Compliance and Accreditation

This job posting is no longer active.

Job ID: 133426
Category: Quality/Performance Improvement
Work Type: FT
Location: Philadelphia, PA, United States
Date Posted: May 11, 2022
Work Schedule: 8:00 - 4:00pm | Onsite, remote flexibility

Save Job Saved


Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?


  • The Director of Regulatory Compliance and Accreditation is responsible for organization-wide readiness. The Director will lead the organization to maintain compliance with standards and regulations for the Center for Medicaid and Medicare Services, PA Department of Health, the Joint Commission, and others, as directed. The Director maintains current knowledge of standards and regulations and advocates for best practices and processes to meet minimum standards. The Director collaborates with stakeholders to facilitate readiness across the hospital and all licensed areas. Additionally, the Director will serve as the entity Privacy Officer. 


  • Provide organizational wide leadership in continuous readiness for the Joint Commission and ongoing compliance with state, federal regulation and other regulatory agencies. Maintains current knowledge of TJC standards, Department of Health and Center for Medicare and Medicaid Services regulations.
  • Oversees regulatory processes for reporting, surveys by accrediting bodies, occupancy requests, etc. Ensures proper documents, surveys and applications are completed timely and accurately. Advocates for a culture of continuous readiness.
  • Leads/Assists in the design of new policies and procedures and the maintenance of existing policies and procedures. Monitors effectiveness of the policies and procedures at Pennsylvania Hospital. Manage and eliminate process workarounds by appropriately and consistently sharing with organizational partners the issues, which require their attention.
    • Analyze the data regularly to identify opportunities for improvement. 
    • Share data with teams and mutually identify opportunities for improvement within the department’s span of influence. 
    • Collaborate with teams to develop action plans for improvement.
    • Implement and follow through with action plan. 
    • Provide education regarding new standards.
  • Acts as an internal consultant to stakeholders within and external to the organization, providing expert opinion and counsel.
  • Ensures appropriate information is sent to governing bodies, including, not limited to the PAH Clinical Effectiveness and Performance Improvement, the Medical Executive Committee and the Board of Managers.
  • Assists, as appropriate, in the investigation and evaluation of significant complaints and occurrence reports concerning patients, families, staff and other customers
  • Ensures the organization follows all HIPAA/Privacy Guidelines including but not limited to: the electronic medical record (EMR), paper, verbal and visual. The Entity Privacy Officer is responsible for organizational education, breach investigations, follow up and Human Resources coordination, where appropriate.
  • Works with Nursing Administration, Nursing Leadership, Entity leadership and CPUP leadership in developing programs, services and initiatives to become a High Reliability Organization. Sets standards and drives operational integration of regulatory efforts by ensuring alignment across teams, environments and entities.


  • Registered Nurse - PA (Preferred).

Education or Equivalent Experience:

  • Master's Degree (Required), Clinical preferred. Non-Clinical with regulatory background and/or Healthcare Administration 
  • 5+ years of Regulatory/ Accreditation, Quality Assurance, Quality Improvement, Healthcare Leadership experience (Required)


  • Strong written and communication skills; ability to interact professionally with a diverse group of clients and staff
  • Highly effective verbal communication and interpersonal skills to establish working relations that foster optimal patient care
  • Ability to work in a highly matrixed structure and have the professional presence to make recommendations to senior leadership
  • Demonstrated organizational leadership skills
  • Ability to use Microsoft Office (Excel, Power Point, Word)
  • Ability to analyze data to synthesize and summarize information, and judgments regarding patient care
  • Demonstrated ability to deal with confidential information
  • Demonstrated ability to collaborate with individuals and influence in various roles and levels
  • Work independently and as a team player
  • Able to deliver clear and concise presentations to varied audiences
  • Experience in the processes surrounding Patient Care Outcomes and Quality Improvement

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

   Current UPHS employees must apply HERE
Share: mail

Similar Jobs