Accreditation Regulatory Specialist bei Lake County, IL

About the Department

Under the supervision of the Clinical Compliance Manager, the Accreditation Regulatory Specialist is responsible for managing regulatory compliance for the Lake County Health Department and Community Health Center’s (LCHD/CHC) federally qualified health centers (FQHC). This role is responsible for ensuring compliance with applicable accreditation and regulatory standards from organizations such as The Joint Commission, HRSA, IDPH and others; and plays a vital role in maintaining a high quality of care, patient safety, and operational efficiency within the ambulatory care environment. 

Position Duties

• Develops and implements activities and programs related to continuous readiness and survey preparation; ensuring ongoing compliance with all accreditation and regulatory requirements.
• Chairs physical health continuous accreditation readiness team (PH CART) committee. 
• Leads Intracycle Monitoring (ICM) activities for the Joint Commission, including creating and monitoring action plans to address gaps in compliance.
• Coordinates environment of care rounds, internal audits, mock surveys, and gap analyses to identify areas of vulnerability and maintain readiness for external surveys.
• Coordinates and facilitates onsite surveys by accrediting and regulatory bodies, acting as a liaison between external evaluators and the organization.
• Manages policy development and policy updates using the LCHD/CHC’s document management system; acts as the subject matter expert for policy development. 
• Interprets complex accreditation and regulatory standards, translating them into clear and actionable policies and procedures.
• Maintains awareness of current internal policies, external regulations, and legislation, providing consultation on their interpretation and implementation.
• Serves as a subject matter expert, advising leadership and staff on compliance issues and best practices in the ambulatory care setting.
• Partners with various departments and leadership to develop and implement performance improvement plans based on audit findings and identified risks.
• Develops and delivers educational programs and resources to ensure all staff members are aware of and understand regulatory and accreditation requirements.
• Communicates regulatory information across departments, ensuring accurate interpretation and implementation of policies, procedures, and applicable standards. 
• Fosters a culture of quality and patient safety through communication and education initiatives.
• Manages/assists with compliance database systems, including data entry, report generation, and ensuring data accuracy and security.
• Develops and utilizes tools for data collection, analysis, dashboard/visual management, and reporting to monitor performance and identify areas for improvement.
• Ensures timely and accurate submission of corrective action plans (CAPs) and other required information to regulatory agencies.
• Collaborates effectively with cross-functional teams, departments, and external stakeholders to achieve objectives related to accreditation and regulatory compliance.
• Serves as a leader within the organization on matters of accreditation and regulation, providing guidance and support to staff and leadership. 
• Maintains a presence at all health centers acting as a resource to staff and leadership. 
• Other duties as assigned.

Minimum Qualifications

• Valid drivers’ license with an acceptable driving record.
• Requires strong leadership and interpersonal skills.
• Considerable knowledge of regulatory standards (e.g., TJC, PCMH, HRSA) in ambulatory healthcare settings. 
• Considerable knowledge of applicable local, state, and federal regulations related to healthcare. 
• Considerable knowledge of The Joint Commission accreditation survey process. 
• Considerable knowledge of quality improvement (QI) or performance improvement methodologies. 

Other Qualifications

As the largest human service provider in Lake County, we believe that services must be available without barriers. No residents are turned away due to the inability to pay. We believe in providing services in an environment of mutual respect, free of discrimination or bias. Whether assuring accessible and effective care, impacting policy, or assessing and monitoring risks, the Lake County Health Department and Community Health Center has been an essential part of the public health system in Lake County for 60 years.We are looking for passionate, qualified team members who can help make a difference in our agency and, most importantly, in our community. 

Additional information about the Lake County Health Department, our culture, and why you should join our team can be found athttps://lakecountyil.attract.neogov.com/health-department.

At this time, you must live in Illinois or Wisconsin to be eligible to work at Lake County Health Department. You can find our salary grades at https://www.lakecountyil.gov/4515/Salary-Grades. For unionized positions, a list of our collective bargaining agreements can be found here: https://www.lakecountyil.gov/2686/Collective-Bargaining-Agreements.

Any offer of employment is conditioned on the successful completion of a background screening, drug and alcohol testing, and may include a pre-employment medical exam.

The Lake County Health Department and Community Health Center is an Equal Opportunity Employer.  We evaluate qualified applicants without regard to race, color, religion, sexual orientation, gender identity or gender expression, national origin, disability, veteran status, and other protected characteristics.