Director of Accreditation and Licensure

Position Title:Director of Accreditation and Licensure

Location: Owensboro, KY 42301

Description:

Job Summary

The Director of Accreditation and Licensure provides organization-wide leadership and oversight for accreditation, licensure, and regulatory readiness across River Valley & Affiliates. The Director serves as the organization's primary subject matter expert for CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation and oversees applicable national accreditation and state licensure requirements across all programs and facilities in Kentucky, New Mexico, and North Carolina.

The position ensures continuous readiness by monitoring regulatory requirements, coordinating surveys and inspections, maintaining required documentation and renewals, identifying compliance gaps, and overseeing corrective action plans. Working collaboratively with executive, clinical, operational, Quality, Compliance, Legal, and other leaders, the Director integrates accreditation and licensure requirements into everyday operations and quality improvement efforts to support regulatory compliance, service quality, and organizational excellence.

Essential Functions

CARF Accreditation Strategy and Oversight

• Serve as the organization's primary point of contact and subject matter expert for CARF (Commission on Accreditation of Rehabilitation Facilities) and applicable CARF standards.
• Maintain a robust CARF readiness plan identifying applicable standards, responsible leaders, required evidence, monitoring activities, and corrective actions.
• Conduct or coordinate periodic CARF readiness assessments, mock surveys, tracer activities, documentation reviews to identify and close compliance gaps before CARF formal surveys.
• Prepare and submit all documentation, evidence, and materials required for CARF accreditation surveys.
• Coordinate the organization's response to CARF surveys, including on‑site survey logistics, document preparation, staff scheduling, and support for surveyors during survey activity.
• Prepare and submit the organization's response to CARF survey findings, including development, submission, and tracking of the Quality Improvement Plan and any required corrective actions following the survey.
• Monitor changes to CARF standards and survey requirements and translate those changes into clear operational expectations for affected departments, programs, and leaders.
• Promote continuous CARF readiness throughout the accreditation cycle rather than episodic preparation immediately before surveys.

Additional National Accreditation Compliance

• Maintain working knowledge of additional national accrediting bodies applicable to the organization's facilities and service lines beyond CARF.
• Coordinate survey readiness, documentation, and response activities for all additional national accreditations held by the organization.
• Monitor changes to standards and requirements across all applicable national accrediting bodies and communicate impacts to affected facilities and departments.
• Maintain a comprehensive organization‑wide calendar of accreditation surveys, licensure and certification renewals, regulatory submissions, corrective action deadlines, and other key compliance dates.

National and State Licensure Compliance

• Maintain expertise regarding applicable facility licensure, program certification, accreditation, and regulatory requirements in Kentucky, New Mexico, North Carolina, and other states in which the organization operates.
• Ensure timely preparation, submission, and renewal of applicable facility licenses, certifications, and regulatory filings, and coordinate or support certificate of need activities as applicable.
• Serve as primary liaison to state licensing and survey agencies and applicable…