Director- Regulatory Compliance

York, PA | Professional | Tracking Code: 54002

Join us at an upcoming event:

Exciting Regulatory Compliance Leadership Opportunity

at WellSpan York Hospital 


York, PA


General Summary:
Under the general supervision of the Vice President & Chief Nursing Officer/COO WYH, plans, directs and implements systems and processes to ensure compliance with the PA Department of Health standards, The Joint Commission standards, the CMS Conditions of Participation and the Department of Public Welfare regulations for York Hospital. Establishes accountability, credibility, and structure to the regulatory compliance initiatives and provides leadership oversight for regulatory compliance. Maintains responsibility for PA Department of Health, Joint Commission and CMS Validation surveys for York Hospital and all provider-based and Hospital owned off site departments/entities. 

Essential job accountabilities:

  1. Reviews, updates, coordinates and provides guidance to formulate policies and procedures regarding regulatory compliance-related activities within operational processes.
  2. Oversees notification and coordination of regulatory activities and regulations for PA Chapter 51 , Joint Commission and CMS Conditions of Participation for the Hospital and all off-site outpatient departments.
  3. Manages and administers the Department of Public Welfare visits for the York Hospital inpatient Behavioral Health unit.
  4. Collaborates and directs the leadership team for all new certifications/accreditations and surveys for the Hospital and all off-site departments.
  5. Establishes a good working relationship with diverse members of surveyors, consultants and leadership team members across all entities.
  6. Supervises and coordinates the Accreditation teams on arrival to the organization as well as directs and assembles the York Hospital survey team members.
  7. Directs the Regulatory Accreditation Coordinator and ensures all required audits are completed in a timely manner.
  8. Responsible for ensuring that all local, State and Federal standards, including the Department of Public Welfare related to licensure, are met and maintained.
  9. Develops and oversees the implementation of all corrective action plans to address survey findings. Monitors and analyzes all data related to action plans and reports results to leadership.
  10. Facilitates and manages the Joint Commission Continuous Standards Review program to ensure ongoing, coordinated assessment, planning, measurement and improvement of standards compliance. Chairs and facilitates the CSR committee.
  11. Initiates, assigns, monitors and analyzes data for all mock tracer activities performed by the CSR Team members. Utilizes findings to initiate improvement and staff education by ensuring compliance with all regulatory standards.
  12. Educates others in interpretation of standards and assists as needed in planning improvement/compliance. Develops, plans, directs and implements staff education programs related to The Joint Commission Survey process and standards.
  13. Manages and coordinates with leaders to ensure accurate information and updates are applied to the Department of Health and Joint Commission applications annually and as needed due to new services.
  14. Provides ongoing reports and updates of existing and potential regulatory compliance issues to York Hospital Senior Leadership and Board of Directors.
  15. 19 Is a resource for the Health System for interpretation of the local, State, Federal and Joint Commission regulations.

About WellSpan:

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multi-specialty medical group of more than 850 physicians and advanced practice clinicians, a home care organization, eight respected hospitals, more than 19,000 employees, and 170 patient care locations. The region's only accredited Level 1 Trauma Center and Primary Stroke Center with an endovascular neurosurgery program. WellSpan is consistently recognized by IMS Health as one of the Top 100 Integrated Health Networks in the United States and has been recognized by Health Imaging and IT as one of the nation's "Top 25 Connected Healthcare Facilities." IMS Health is the leading provider of information services and technology for the healthcare industry. 

The Community:

WellSpan Health facilities are located in multiple counties across south central Pennsylvania and northern Maryland, all offering an ideal living environment to match the quality of work-life balance you’re seeking. The area offers abundant outdoor and cultural activities, including restaurants, theatre, golf courses, hiking trails, water sports and historic tours. Additionally, our communities are a short drive from several, large metropolitan areas including the Baltimore/DC metro area and Philadelphia.

If you value a strong sense of community, the more palatable pace of rural living, and the convenience of a workplace close to home, you’ll realize the advantages of considering WellSpan Health as part of your future.

Required Skills
  • Master's degree in Business or Healthcare Administration preferred
  • Project Management, strong analytical, and proven leadership skills required
  • Demonstrated ability to assess
  • A proven record of accomplishment of working effectively with all levels of staff within a large hospital setting.
  • Demonstrated ability to develop and implement significant initiatives within a complex, matrixed environment.
Required Experience
  • 7 years of management experience with demonstrated knowledge of health care and regulatory affairs

  • Extensive experience with regulatory surveys 

  • A proven record of accomplishment of working effectively with all levels of staff within a large hospital setting.

  • Demonstrated ability to develop and implement significant initiatives within a complex, matrixed environment.

Quality of Life

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multispecialty medical group of more than 1,200 physicians and advanced practice clinicians, a regional behavioral health organization, a home care organization, six respected hospitals, more than 15,000 employees, and 140 patient care locations. WellSpan is a charitable, mission-driven organization, committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Quality of Life
Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)

Equal Opportunity Employment

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

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