Accreditation and Regulatory Advisor

Accreditation & Regulatory Advisor (Critical Access Hospitals)

The Accreditation & Regulatory Advisor serves as a subject matter expert in accreditation, regulatory compliance, and survey readiness across IU Health's Critical Access Hospitals. This position is responsible for facilitating accreditation and regulatory compliance activities within assigned facilities while providing readiness support and consultation to additional IU Health facilities as needed. 

Working collaboratively with operational leaders, clinical teams, and key stakeholders, the advisor promotes a culture of continuous survey readiness and regulatory compliance. The role provides education, consultation, and expert guidance regarding accreditation standards, regulatory requirements, and compliance best practices to support safe, high-quality patient care.

While the role is currently based out of IU Health Frankfort Hospital, flexibility may be considered regarding the home-base location based on the selected candidate's geographic location and organizational needs. Regular interfacility travel is required to support survey readiness, accreditation activities, and regulatory compliance initiatives.

Schedule: Monday-Friday, Day Shift

Key Responsibilities

• Serves as the primary accreditation and regulatory compliance resource for assigned Critical Access Hospitals and provides interfacility support throughout the IU Health system.
• Acts as a trusted advisor to leaders and stakeholders by interpreting accreditation standards, state and federal regulations, and organizational compliance requirements.
• Plans, coordinates, and facilitates survey readiness activities, including mock surveys, tracers, education sessions, and readiness assessments.
• Leads onsite accreditation and regulatory surveys, coordinating activities before, during, and after survey events to ensure successful execution.
• Develops, coordinates, and monitors comprehensive corrective action plans in response to survey findings, deficiencies, or identified compliance gaps.
• Prepares written responses to regulatory agencies and accrediting organizations and ensures timely completion of all required follow-up actions.
• Proactively evaluates new or revised services, programs, workflows, and physical spaces to assess regulatory and accreditation compliance requirements prior to implementation.
• Partners with operational and clinical leaders to identify opportunities for improvement and restore compliance when regulatory risks or deficiencies are identified.
• Analyzes regulatory changes and communicates impacts, recommendations, and action plans to leaders and stakeholders.
• Provides regular readiness and compliance updates to facility and system leadership, including assessment of compliance risks and mitigation strategies.
• Serves as the facility liaison for communications with the Indiana Department of Health and applicable accrediting organizations.
• Promotes a culture of continuous readiness through education, coaching, collaboration, and process improvement activities.
• Participates in systemwide regulatory and accreditation initiatives, special projects, and performance improvement efforts.

Qualifications

• Bachelor's Degree is required.
• Requires 4-6 years of relevant experience.
• CPHQ or other comparable healthcare regulatory certification endorsed by IU Health System Regulatory Affairs required within two years of employment.
• Interfacility travel for surveying and in-state overnight stays is required.
• Requires current state of Indiana license as a health care professional (e.g., Registered Nurse with an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license, Respiratory Therapist, Pharmacy or Rehabilitation license).