Director Regulatory and Accreditation in Nashville, Tennessee, United States
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HCA Healthcare

Director Regulatory and Accreditation

Nashville, TN, United States
Full-time • No Weekends
Directors and Managers   Job ID: 891189
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This position is incentive eligible.


Do you want to join an organization that invests in you as a(an) Director Regulatory and Accreditation? At HCA Healthcare, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years.


HCA Healthcare, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

  • Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
  • Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
  • Free counseling services and resources for emotional, physical and financial wellbeing
  • 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
  • Employee Stock Purchase Plan with 10% off HCA Healthcare stock
  • Family support through fertility and family building benefits with Progyny and adoption assistance.
  • Referral services for child, elder and pet care, home and auto repair, event planning and more
  • Consumer discounts through Abenity and Consumer Discounts
  • Retirement readiness, rollover assistance services and preferred banking partnerships
  • Education assistance (tuition, student loan, certification support, dependent scholarships)
  • Colleague recognition program
  • Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
  • Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Director Regulatory and Accreditation like you to be a part of our team.

Job Summary and Qualifications

The Director of regulatory and accreditation is recognized as an expert within the organization for clinical operational assessments related to compliance with federal regulations, accreditation standards, and state statutes. The director travels to provide onsite expert consultation and perform survey activity for the HCA Healthcare Continual Survey Readiness Evaluation (CSRE) team that supports HCA Healthcare acute care facility and ambulatory surgery center (ASC) administrator/chief executive officers (CEO), chief nursing officers (CNO) and other hospital/ASC, board of trustee and medical staff leaders regarding clinical performance improvement and foundational operational standards requiring facility compliance. Role is critical to HCA Healthcare strategy of quality and patient safety and risk reduction as a differentiator of hospital and ASC operational performance. Role complements and provides guidance to division vice president, quality or director, quality and risk management. This position requires up to 75% of travel.

Major Responsibilities:

oResponsible for the assessment, planning, coordination and development of expert consultation and education to HCA Healthcare acute care facility senior leaders on foundational regulatory and accreditation compliance

oServes as subject matter expert for CMS and TJC leadership, clinical, and operational aspects of performance. Serves as resource for Environment of Care and Life Safety

oWorks in an advisory capacity for facility directors for all regulatory and accreditation compliance

oAssists facilities with the preparation for CMS and TJC surveys and provides support when a facility receives an adverse decision and/or condition-level finding during external survey process

oConducts ongoing research to remain current with regulatory requirements from CMS, TJC, Occupational Safety and Health Agency (OSHA) and others

oWith increasing HCA Healthcare clinical improvement patient quality agenda and increasing intensity in regulatory and accreditation survey activity, this position is critical to HCA Healthcare mission and strategies.

•Role complements and provides guidance to division/regional leaders of quality, risk, and safety. Role serves as expert consultant to acute care and ASC facility senior leaders (CEO, COO, CNO, CMO, etc.) on topics of foundational regulatory and accreditation compliance, performance improvement, and risk reduction.

•Collaborates as a crosscutting function across multiples corporate teams, committees, and projects as a forward-facing leader of Regulatory and Accreditation Services to ensure enterprise work products are compliant with external regulatory and accreditation requirements

•Drives enterprise wide regulatory and accreditation compliance and performance based on internal and external metrics through project management and timely delivery of work products

•Designs and presents educational programs for HCA Healthcare hospital/ASC and medical staff leaders regarding requirements of clinical performance improvement for operational compliance to public reporting including the hospital quality alliance, external quality agencies including The Joint Commission (TJC)/Accreditation Association for Ambulatory Health Care (AAAHC), Centers for Medicare and Medicaid Services (CMS), state survey agencies, etc.

•Conducts onsite assessments of focused topics within HCA Healthcare hospitals/ASCs including credentialing, utilization management, peer review, medical staff and board bylaws, etc.

•Position demands a total command of clinical performance improvement, clinical excellence, HCA Healthcare clinical agenda, TJC and AAAHC standards, healthcare licensure regulations and CMS Conditions of Participation/Conditions for Coverage. Position is critical to advancement of HCA Healthcare facility delivery of safe, effective, efficient, compassionate and satisfying patient care as defined by the HCA Healthcare clinical improvement strategies.

Education & Experience:

•Bachelor's degree required

•Master's or Doctoral degree preferred

•5+ years of experience in a relevant work experience including experience with Regulatory and/or Accreditation entities as it relates to external survey activity

•Registered nurse, registered pharmacist, registered or accredited health information administrator, healthcare administrator or other licensed healthcare professional.

•Consulting and educational program delivery skills and expertise.

•Computer knowledge and competency for presentation design and report delivery.

•Expert speaking, presentation skills, executive presence, and competency.

•Must be a team participant focused toward HCA Healthcare clinical improvement strategies.

•Long-term position commitment required.

•Consulting days (on-site/travel) 12-14 hours/day required

HCA Healthcare (Corporate), based in Nashville, Tennessee, supports a variety of corporate roles from business operations to administrative positions. Like our colleagues in any HCA Healthcare hospital, our corporate campus employees enjoy unparalleled resources and opportunities to reach their potential as healthcare leaders and innovators. From market rate compensation to continuing education and career advancement opportunities, every person has a solid foundation for success. Nashville is also home to our Executive Development Program, where exceptional employees are groomed to take on CNO- and COO-level roles in our hospitals. This selective program focuses on ethics, leadership and the financial and clinical knowledge required of professionals at this level of the industry.

HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"Good people beget good people."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Director Regulatory and Accreditation opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.


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Directors and Managers
Full-time • No Weekends

About HCA Healthcare

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