Duke University Health System (DUHS) Job Descriptions

ASSIST DIR, ACCRED/REGULATORY AFFAIRS

Job Title: ASSIST DIR, ACCRED/REGULATORY AFFAIRS
Job Code: 5666
FLSA: E
Job Level: H2
Revised Date: 06/01/2025
Supervisory Responsibility: Yes

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General Description of the Job Class

The Assistant Director, Accreditation and Regulatory, is responsible for leading system accreditation and regulatory programs at Duke University Health System (DUHS). This role involves collaboration with leadership, staff, and medical staff to ensure compliance with accreditation, regulatory, and disease-specific certification requirements. This role requires a systems thinker who can lead system/entity effort to achieve the highest compliance with accreditation and certification standards with an approach to ensuring practices not only meet but exceed benchmarks for patient care excellence. A systems thinker, the Assistant Director leads efforts across the system and entities to achieve the highest levels of compliance, aiming not only to meet but to exceed benchmarks for patient care excellence. The role is instrumental in shaping and supporting the infrastructure for sustained accreditation success by applying deep expertise in regulations, standards, and improvement methodologies. This position also champions cross-entity collaboration to align priorities and drive standardization in accreditation and regulatory practices, elevating system-wide effectiveness and readiness. The Assistant Director operationalizes an effective continuous readiness framework that supports and sustains the DUHS Accreditation and Regulatory Program's core goals of: 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations.

Duties and Responsibilities of this Level

Continuous Readiness Efforts:

Lead the entity for the evaluation, planning, and support of continuous compliance and readiness infrastructure.

Oversee pre-survey, on-site survey and post-survey activities for accreditation, regulatory and certification programs.

Collaborate with leaders and departments to assess policies, evaluate workflows, and observe clinical care to identify gaps and ensure compliance with standards.

Partner with Patient Safety, Quality, Professional Practice, Risk Management, Legal, and other departments to assess regulatory functions and maintain compliance.

Conduct ongoing monitoring, measurement, and analysis of survey data and trends, and communicate results to appropriate departments and leadership.

Develop and maintain entity comprehensive accreditation project plan. Resource Development and Management

Create and maintain toolkits, educational resources, and reference materials to support accreditation and certification readiness.

Deliver training and presentations related to regulatory, accreditation, and disease-specific certification requirements.

Ensure regulatory resources are up to date and communicate changes to leadership and staff.

Collaborate with clinical and administrative departments to implement changes that enhance compliance with standards and improve patient outcomes.

Survey Coordination:

Serve as the primary liaison between accreditation/regulatory bodies and the entity.

Develop, maintain, and implement an entity-specific unannounced survey plan.

Manage on-site accreditation, regulatory, and certification surveys, including communications, agendas, and logistics.

Support the development and execution of corrective action plans in response to survey findings.

Oversee reporting requirements for state and federal regulatory agencies.

Program Management:

Manage the accreditation and certification budget plan.

Develop and manage the Accreditation Readiness Committee meetings and activities.

Monitor changes in federal and state regulations and accreditation standards, and communicate changes to leadership and staff.

Enhance continuous improvement activities by acquiring and teaching performance and process improvement concepts and methodologies.

Champion cross-entity collaboration to align priorities and drive standardization in accreditation and regulatory practices across the health system.

Required Qualifications at this Level

Education

Bachelor's degree in Nursing, Business, Healthcare Administration, or a related field. Master's degree preferred.

Experience

Minimum of 7 years of experience working with accreditation, certification, quality, risk management, patient safety, or clinical operations.

Knowledge of quality improvement methodologies, project management, and regulatory standards (CMS, TJC, DNV, DOH).

Experience with auditing/data analytics, staff training, and creative problem-solving strategies preferred.

Must be able to work on-site to ensure readiness for unannounced surveys.

Preferred qualifications: Management experience, especially with clinical operations in a clinical healthcare environment preferred.

Previous accreditation readiness experience, experience with project management systems/leadership experience strongly preferred.

Degrees, Licensure, and/or Certification

RN or other clinical professional with current licensure preferred.

Preferred certifications: CPHQ (Certified Professional Healthcare Quality), Certified Quality Technician (ASQ), HACP (Healthcare Accreditation Program), or CSHA (Certified Specialist in Healthcare Accreditation).

Knowledge, Skills, and Abilities

Highly self-motivated, self-directed and independent thinker using independent judgment.

Knowledge of deemed status accrediting organization standards and regulatory compliance issues.

Strong problem-solving, analytical, and negotiating skills.

Ability to develop, prioritize, and accomplish goals.

Positive interpersonal skills and the ability to work effectively in a team environment.

Strong analytical, facilitation, coaching, written, and verbal skills.

Flexible with changes, processes, and procedures to meet program/plan needs.

Ability to use discretion and independent judgment when obtaining, compiling, and distributing information and data.

Experience within an organization with complex relationships and multiple stakeholders that may have conflicting goals and priorities.

Demonstrated ability to manage conflict, build, support, mentor and monitor teams and the ability to recognize and address positive behaviors that contribute to successful achievement of plan goals.

Distinguishing Characteristics of this Level

N/A

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The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

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Duke University is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, (including pregnancy and pregnancy related conditions), sexual orientation, or military status.

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Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.