Accreditation Regulatory Specialist

Under the supervision of the Clinical Compliance Manager, the Accreditation Regulatory Specialist is responsible for managing regulatory compliance for the Lake County Health Department and Community Health Center’s (LCHD/CHC) behavioral health programs. This role is responsible for ensuring compliance with applicable accreditation and regulatory standards from organizations such as Joint Commission (TJC), Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA), Illinois Department of Human Services (DHS), Illinois Department of Healthcare and Family Services (HFS), Illinois Division of Behavioral Health & Recovery (DBHR), Illinois Department of Public Health (IDPH) and the Centers for Medicare & Medicaid (CMS), and others;

and plays a vital role in maintaining a high quality of care, client safety, and operational efficiency within the behavioral health environment.

Scheduled

Hours:

40 hours per week

• Develops and implements activities and programs related to continuous readiness and survey preparation; ensuring ongoing compliance with all accreditation, regulatory, and licensure requirements.
• Chairs behavioral health continuous accreditation readiness team (BH CART) committee.
• Leads Intracycle Monitoring (ICM) activities for the Joint Commission, including creating and monitoring action plans to address gaps in compliance.
• Coordinates internal audits, mock surveys, and gap analyses to identify areas of vulnerability and maintain readiness for external surveys.
• Coordinates and facilitates onsite surveys by accrediting and regulatory bodies, acting as a liaison between external evaluators and the organization.
• Manages policy development and policy updates using the LCHD/CHC’s document management system; acts as the subject matter expert for policy development, and ensures all BH policies are current within the established review timeframe.
• Interprets complex accreditation and regulatory standards, translating them into clear and actionable policies and procedures.
• Maintains awareness of current internal policies, external regulations, and legislation, providing consultation on their interpretation and implementation.
• Serves as a subject matter expert, advising leadership and staff on compliance issues and best practices in the behavioral health setting.
• Partners with various departments and leadership to develop and implement performance improvement plans based on audit findings and identified risks.
• Develops and delivers educational programs and resources to ensure all staff members are aware of and understand regulatory and accreditation requirements.
• Communicates regulatory information across departments, ensuring accurate interpretation and implementation of policies, procedures, and applicable standards.
• Fosters a culture of quality and client safety through communication and education initiatives.
• Manages/assists with compliance database systems, including data entry, report generation, and ensuring data accuracy and security.
• Develops and utilizes tools for data collection, analysis, dashboard/visual management, and reporting to monitor performance and identify areas for improvement.
• Ensures timely and accurate submission of corrective action plans (CAPs) and other required information to regulatory agencies.
• Collaborates effectively with cross-functional teams, departments, and external stakeholders to achieve objectives related to accreditation and regulatory compliance.
• Serves as a leader within the organization on matters of accreditation and regulation, providing guidance and support to staff and leadership.
• Maintains a presence at all behavioral health sites acting as a resource to staff and leadership.
• Facilitates mortality review sessions following the death of BH clients in line with the requirements of the Client Mortality Awareness and Review policy.
• Assists with requests from the Office of Inspector General (OIG) when investigations are initiated to ensure all required documentation is submitted by established time frames.
• Other duties as assigned.

• Valid drivers’ license with an acceptable driving record.
• Strong leadership and interpersonal skills.
• Considerable knowledge of regulatory standards (e.g., TJC, PCMH, HRSA, SAMHSA) in behavioral healthcare settings.
• Considerable knowledge of applicable local, state, and federal regulations related to behavioral health.
• Considerable knowledge of The Joint Commission accreditation survey process.
• Considerable knowledge of quality improvement (QI) or performance improvement methodologies.
• Ability to prioritize work responsibilities and meet established deadlines.

As the largest human service provider in Lake County, we believe that services must be available without barriers. No residents are turned away due to the inability to pay. We believe in providing services in an environment of mutual respect, free of discrimination or bias. Whether assuring accessible and effective care,…