Director of Regulatory Affairs - Sibley Memorial Hospital

This is a hybrid role which will be supporting Sibley Memorial Hospital which is a non-profit, full service 318 bed acute care community hospital serving the Washington, DC area. Sibley offers medical, surgical, intensive care, obstetric, oncology, orthopedic and skilled nursing inpatient services, as well as a 24-hour Emergency Department. Sibley’s campus is also home to Grand Oaks, an assisted living residence; a medical building with physician offices and ambulatory surgery and imaging centers; and the new patient tower with 200 spacious, private rooms.  

The Director of Regulatory Affairs is responsible for planning, organizing, implementing, and evaluating regulatory compliance initiatives that support patient safety, quality outcomes, and continuous compliance with federal, state, and local regulatory requirements. This role provides oversight of accreditation and certification activities, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and State/Local Department of Health (DOH) standards, regulations, and laws, in consultation with legal counsel as needed.

Key responsibilities include:

• Interpreting and operationalizing regulatory requirements
• Supporting regulatory communications and notifications
• Providing staff and leadership education related to regulatory standards
• Developing and revising policies and documentation
• Coordinating virtual and onsite accreditation and regulatory surveys
• Coordinating mock surveys conducted by external consultants or the JHHS Office of Accreditation & Certification (OAC)
• Developing corrective action plans and monitoring long-term compliance improvements
• Collaborating on special projects
• Serving as a regulatory resource and consultant to internal and external stakeholders
• Participating in organizational and health system committees

Essential Functions

Continuous Readiness Program

• Provides strategic and operational leadership to ensure readiness for both patient care and regulatory surveys.
• Oversees a continuous regulatory readiness program, including tracer activities, educational initiatives, data collection, analysis, and reporting.
• Chairs or co-chairs a regulatory continuous readiness committee.
• Maintains regulatory online portals, including TJC intranet sites and extranet application submissions.
• Remains current on regulatory requirements and serves as a subject matter expert to staff, providers, and leadership regarding new or revised standards.

Survey Management

• Plans and directs virtual and onsite surveys, including:
  • Accreditation and certification surveys
  • Extension surveys
  • Licensure surveys
  • Validation surveys
  • Complaint surveys
  • Designation surveys
• Develops and maintains an unannounced survey readiness plan.
• Manages survey command center operations and serves as the primary liaison for surveyors.
• Advises staff and providers throughout survey activities.
• Partners with stakeholders to develop, review, and monitor corrective action plans.
• Leads and participates in interdisciplinary teams to improve workflows, policies, and documentation to achieve regulatory compliance.

Patient and Staff Complaints from External Regulators

• Collaborates with internal stakeholders to investigate, review, and respond to complaints received from external regulatory and accreditation agencies.

Education

• Master's Degree required; healthcare-related field preferred.
• Undergraduate degree from an accredited school of nursing, public health, or related clinical discipline preferred.

Experience

• Minimum of 8-10 years of healthcare-related experience required.
• Demonstrated knowledge of accreditation and certification processes.
• Experience with performance improvement methodologies and quality improvement tools.
• Minimum of 2 years of direct management experience.
• Experience in regulatory compliance, quality/performance improvement, patient safety, risk management, or project management preferred.

Licensure and Certification

• Certified Professional in Healthcare Quality (CPHQ) preferred.

Knowledge, Skills, and Abilities

• Ability to work independently and effectively in unstructured environments.
• Strong verbal, written, and interpersonal communication skills.
• Ability to interact effectively with all levels of leadership and staff.
• Ability to communicate complex regulatory requirements clearly and effectively.
• Strong analytical and reporting capabilities.
• Excellent technical and business writing skills.
• Advanced proficiency with Microsoft Word, Excel, and PowerPoint.
• Knowledge of electronic medical record systems and medical record auditing.
• Strong attention to detail due to the regulatory and legal implications of the role.

What We Offer

Johns Hopkins Health Plans is an organization that recognizes and rewards excellence and encourages professional development. Employee rewards, recognition, camaraderie and support are just a few of our many benefits include tuition assistance, dependent college tuition program, 403(b) retirement savings, health, dental vision and prescription coverage, disability and life insurance, paid time off and holidays.