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   Current UPMC employees must apply in HR Direct

Director, Regulatory and Accreditation

  • Job ID: 299030427
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Susquehanna Williamsport
  • Department: QUALITY
  • Location: 700 High Street, Williamsport PA 17701
  • Union Position: No
  • Salary Range: $38.06 to $57.09 / hour


The purpose of the Director, Regulatory and Accreditation role is to assist in providing enterprise wide leadership and overall strategic direction in the area of regulatory oversight. The Director role will assist in the development of the goals of the organization and be involved with the many different facets of the specified region.



  • Provides collaborative leadership on a consistent basis that smoothes the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and the local initiatives.
  • Serve as the internal consulting resource for regulatory while staying abreast of developments in the field.
  • Effectively participates and engages in activities to support and achieve UPMC strategic goals.
  • Supports the creation of a learning environment. Coaches and advises peer professional staff in the formulation of their development plan.
  • Collaborates with professionals across UPMC to identify and support joint educational opportunities to change clinical practice.
  • Oversees multiple multidisciplinary teams, as assigned, in the development and ongoing progress to achieve organizational objectives of reducing resource utilization while promoting quality patient outcomes. Assures implementation of changes in clinical care or process improvement based on clinical findings, team recommendations, and research literature to promote cost/quality outcomes.
  • Establishes and implements organizational regulatory guidelines. Leads/forms problem solving teams around improvement issues. Seeks resolution of problems and/or issues through team efforts when appropriate. Recommends changes to policies and procedures to senior leadership.
  • Develops relationships and integrates all team members into the team's work. Reports program findings, results, and changes at various settings and meetings. Forms relationships with various settings in the continuum of care based on program issues/work. Assures that the patient care outcomes are achieved. Investigates and implements creative methods for improving patient safety and regulatory issues.
  • Ensure that health services division regulatory and accreditation policies are current and compliant with all requirements.
  • Regularly update local and system management on status of regulatory performance at all UPMC facilities.
  • Standard Responsibilities: Performs in accordance with system-wide competencies/behaviors. Performs other duties as assigned.
  • Creates an excellent employee environment at the UPMC North Central Region.
  • Collaborates/Supervises Quality Coordinators at all campuses in establishing successful practices and conducting reviews across UPMC.
  • Monitor and coordinate compliance activities with other departments to remain abreast of the status of all compliance and patient safety issues to identify trends.
  • Collaborate with leadership, medical staff and service partners to ensure success in meeting regulatory requirements and maintaining a safe quality patient care setting.
  • Identify potential areas of patient safety and regulatory compliance vulnerabilities and risk, develop and implement corrective action plans for resolution of problematic issues, and provide guidance to leadership, medical staff and service partners on how to avoid or deal with similar situations in the future via proactive risk assessments.
  • In conjunction with the Chief Quality Officer, the Director will assist in establishing the overall strategic direction of the specified region for the support of all enterprise wide functions.
  • Utilize and implement appropriate data management systems that support initiatives in patient safety and regulatory.
  • Demonstrates responsiveness to the changing priorities and targets in the field of regulatory initiatives. Provides knowledge in the ongoing growth of knowledge of regulatory fields.
  • Act as a liaison with outside regulatory agencies, resources ad support systems to help ensure UPMC's strategic goal of safe, quality patient care and regulatory excellence.
  • Covers the North Central System Patient Safety Officer, as needed.
  • Utilize and implement appropriate data management systems that support initiatives in patient safety and regulatory.
  • Supports the creation of a learning environment. Coaches and advises peer professional staff in the formulation of their development plan.



  • Master's degree in health care and/or systems field with operational experience in healthcare is preferred.
  • A combination of Bachelor's degree and experience may be considered.
  • Knowledge of patient safety, accreditation process and regulatory agencies (DOH, TJC, CMS) are required.
  • Three (3) years of experience with survey coordination of same is strongly preferred.
  • Experience in effective presentation of efforts to multi-professional executive groups.
  • Excellent interpersonal skills and leadership qualities.
  • Able to lead groups independently and facilitate change across a large complex organization.
  • Ability to effectively present to Senior Executives and Leaders of UPMC.

Licensure, Certifications, and Clearances:

  • Registered Nurse (RN)

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct

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