Director Regulatory and Accreditation Affairs

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

The Director of Regulatory and Accreditation Affairs ensures organizational adherence to state and federal regulatory rules and regulations and accreditation standards while providing strategic oversight of critical compliance functions throughout the Parkland Health System. Safety Post

Minimum Specifications

Education

• Master's degree in healthcare-related field or business is required.

Experience

• Seven (7) years of experience leading Regulatory and Accreditation programs
• Two (2) years of management experience in a healthcare setting required.

Equivalent Education and/or Experience      

• An equivalent combination of education, and experience in leading Regulatory & Accreditation programs in large, complex organizations, may substitute for both the education and the experience requirements.

Certification/Registration/Licensure

• Certified Professional in Healthcare Quality (CPHQ) certificate or
• Healthcare Accreditation Certification Program (HACP) certificate is preferred.

Skills or Special Abilities

• Excellent verbal and written communication skills, including the ability to communicate effectively and professionally across disciplines and with various constituents and articulate complex information in understandable terms.
• Demonstrated ability to coach and influence for results.
• Exceptional knowledge of regulations, rules, and/or standards that apply to the healthcare environment, including, but not limited to, Centers for Medicare & Medicaid Services (CMS), Texas Administrative Code (TAC), The Joint Commission Standards and Elements of Performance (EPs),
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
• Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
• Ability to work in challenging situations involving competing interests, with high-level interdisciplinary groups.
• Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Sound business acumen.
• Proficient in Microsoft Office and other software (e.g., Word, Excel, PowerPoint, Project, etc.).

Responsibilities

Regulatory & Accreditation Leadership

• Oversee the design, implementation, and maintenance of Parkland’s Regulatory & Accreditation Program, ensuring compliance with CMS, TJC, state, county, and local requirements.
• Lead survey preparation, intra-cycle monitoring, and gap closure efforts with health system leaders.
• Maintain strong relationships with regulatory agencies and serve as a subject matter expert for the team.
• Chair the system-wide Survey Readiness Committee and other key committees.
• Stay ahead of evolving regulations, providing updates and guidance to stakeholders.
• Conduct audits, identify gaps, and develop corrective action plans to sustain compliance.
• Oversee tracer activities, data analysis, and reporting for senior leadership and the Board.
• Cultivate an audit-ready culture focused on documentation accuracy and compliance.

Operational & Financial Oversight

• Guide budget planning, monitor financial performance, and implement action plans to optimize resources.
• Ensure operational efficiency while considering financial implications for new or modified programs.
• Maintain staffing levels within targets and manage workforce trends through data-driven decision-making.

Talent & Culture Development

• Recruit and retain a diverse workforce that reflects the communities served.
• Foster an inclusive, collaborative, Fair, and Just environment aligned with Parkland’s ICARE and HRO values.
• Ensure orientation, ongoing training, and competency verification for all team members.
• Oversee HR metrics like retention, engagement, and vacancy rates, driving continuous improvement.
• Conduct regular team meetings, mentor employees, and support professional development.
• Ensure licensure and certification compliance while maintaining high ethical and operational standards.

Job Accountabilities

1. Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
4. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
5. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of Parkland.
6. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.