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Director, Regulatory and Accreditation Compliance

Job Description

Job ID: 1212785
Employment Status: Full-Time
More Information:

BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and mid-Missouri regions. BJC serves patients and their families in urban, suburban and rural communities through its 15 hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice.


Role Purpose

Compliance with Federal, State, Joint Commission and other regulatory bodies are foundational to achieving our goals of creating a culture of safety and accountability within a learning health system. The BJC Director of Regulatory and Accreditation Compliance is responsible for coordinating with the patient safety, legal, regulatory and compliance representatives from Shared Services, as well as from each health services organization (HSO) to lead the development and implementation strategies for an effective survey readiness program. This includes development of education and communication about successful survey tactics and to address problematic regulations. The Directory of Regulatory and Accreditation will develop and/or participate in development of system­ wide policies in collaboration with BJC Legal and Compliance departments to ensure compliance with regulatory and accreditation bodies. This director will also serve as leader for the following system-wide groups: Regulatory Sharing Group, Feedback Governance Council and Abuse Allegations SWAT Team. Leadership responsibilities will also include consultant to Center for Clinical Excellence (CCE) teams working on standardization of care delivery practice and processes.


  • Build and provide strategic direction for a comprehensive regulatory and accreditation program throughout all BJC hospital and service organizations.
  • In collaboration with clinicians, BJC Legal and Compliance, provides direction for HSO Regulatory and Accreditation representatives to develop standard interpretations of regulatory standards and guidelines.
  • Directs system-wide teams including Regulatory Sharing Group, Feedback Governance Council (patient complaint management) and the Abuse Allegations SWAT team. Serves as a consultant to other system-wide teams including Collaborative Practice Council, Clinical Leadership Council and Epic Triage and Standardization teams.
  • Serves as the BJC leader to our regulatory and compliance bodies to stay apprised of new regulations, advocate for our HSOs as new regulations are developed and as existing regulations are being applied and enforced during surveys.
  • With HSO and CCE Executive Leadership, will spread actions necessary to be compliant with regulations and improve patient care.
  • Directs CCE team members working in the areas of regulatory and accreditation readiness, as well as the including policy and procedure program development, management of system policies and patient feedback management.
  • BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job.

  • Minimum Requirements



  • Master's Degree


  • 10+ years

    Supervisor Experience

  • 5-10 years


    Preferred Requirements and Additional Job Information


    Licenses & Certifications

  • Cert/Lic in Area of Expertise

  • Benefits Statement

    Note: not all benefits apply to all openings

    -  Comprehensive medical, dental, life insurance, and disability plan options
    -  Pension Plan*/403(b) Plan
    -  401(k) plan
    -  Tuition Assistance
    -  Health Care and Dependent Care Reimbursement Accounts
    -  On-Site Fitness Center (depending on location)
    -  Paid Time Off Program for vacation, holiday and sick time

    *Pension does not apply to Memorial Hospital, Memorial Hospital East, Alton Memorial or Parkland Health Center

    Legal Statement

    The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.


    Equal Opportunity Employer