• Job Description

  Req#: JR109541

  Where compassion meets innovation and technology and our employees are family.

  Thank you for your interest in joining our team! Please review the job information below.

  The Director of Accreditation & Regulatory is responsible for the strategic oversight, development, and implementation of all accreditation and regulatory initiatives across the organization. This role ensures continuous compliance with applicable standards and regulatory requirements, with a primary focus on maintaining Joint Commission accreditation. The Director collaborates closely with departments and senior leadership to drive organizational readiness, support performance improvement, and ensure a culture of quality and compliance.

  The Director will also oversee the preparation of regulatory documentation, including the Focus Standards Assessment, and lead the organization’s response to accreditation surveys and regulatory changes.

  Key Responsibilities:

  • Lead the development, direction, and oversight of all organizational accreditation and regulatory programs

  • Ensure ongoing compliance with The Joint Commission, state/federal regulations, and other applicable standards

  • Update and maintain Joint Commission applications and complete the Focus Standard Assessment

  • Develop and implement communication plans to inform staff and leadership of regulatory updates and changes

  • Maintain and manage regulatory correspondence and documentation

  • Conduct regular meetings with departments to review requirements and ensure continuous survey readiness

  • Provide guidance and oversight to leadership and staff regarding compliance and regulatory expectations

  • Collaborate with Decision Support in preparing and reviewing reports and data

  • Serve as a mentor and provide leadership to direct reports and colleagues

  • Ensure hospital-wide compliance with all accrediting and regulatory agencies

  • Act as an improvement coach using the Model for Improvement and support performance improvement projects and FMEAs

  • Lead regulatory-related educational initiatives such as New Hire Orientation, Error Prevention, and leadership training

  • Travel to the RGV hospital and affiliated facilities as needed to support regional readiness

  • Perform other duties as required to support the Center for Quality and Safety and broader organizational goals

  Education & Experience:

  • Bachelor’s degree (B.A. or B.S.), Bachelor of Science in Nursing preferred. MS or MSN preferred.

  • Leadership experience preferred.

  • Minimum of 6 years clinical, quality or regulatory

  Certificates, Licenses, Registrations:

  • Current Texas State RN license preferred.

  • Certified Professional in Health Care Quality (CPHQ) or other relevant certification preferred.

  • Active unrestricted Drivers License required.

• About the company

  Making a difference in the lives of children in South Texas

Notice