Division Director of Regulatory Compliance in San Antonio, Texas, United States
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Division Director of Regulatory Compliance

San Antonio, TX, United States
Full-time  No Weekends 
Category: Directors and Managers • Job ID: 08164-109570

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SHIFT: No Weekends
SCHEDULE: Full-time

Here at Methodist Healthcare, our everyday decisions are founded on compassion. Apply today and join a team that is dedicated to serving others in need.

We offer you a generous benefits package including:

  • Medical, Dental, disability and life insurance
  • Flexible Spending Accounts
  • Paid Time Off
  • Employee Discount Program
  • Employee Stock Purchase Program
  • 401k Matching
  • Tuition Reimbursement
  • Student Loan Repayment Program

We are seeking a Division Director of Regulatory Compliance for Methodist Healthcare System.    The Division Director of Regulatory Compliance is responsible for establishing and implementing processes to support ongoing compliance and survey readiness for all regulatory agencies interacting with the facilities in the Methodist Healthcare System (MHS); working cooperatively with all internal and external customers, continuously improving processes in order to improve regulatory compliance; and using resources efficiently and effectively.  We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply now!

What You Will Do In Your Role:

  • Facilitates Proactive Preparation for Survey Readiness to include mock surveys through tracer activities, annual self-assessment (ICM-FSA). Establishes policies and procedures for maintaining regulatory compliance. Reviews current policies and procedures, and then identifying possible gaps in regulatory compliance and then collaborate with teams to close the gaps.
  • Conducts Accreditation Management Program (AMP) software training and monitoring as a means to provide oversight for standard compliance and follow up. Serves as AMP Site administrator for password set –up, etc. Serves in a consultant role to assist in achieving and maintaining regulatory compliance. Provides current regulatory updates and interpret/educate as needed and checks TJC website daily and distribute correspondence. Reviews TJC reports from other facilities and send out lessons learned with our RAFT leaders and distributes articles and regulatory updates.
  • Supports MHS Leadership and staff in preparing for unannounced surveys such as JC, TDSHS, CMS, and OSHA and reports on compliance status. Oversees internal tools that facilitate proactive self-assessment (PPR), monitoring of outcomes and continued readiness for site visits in conjunction with Sr. Leaders and Care Excellence Pillars. Ensures compliance with consent forms, American Disability Act (ADA), patient rights, etc. in coordination with the VP of Ethics and Compliance. Takes a leadership role in oversight of quality metrics for clinical contracts and mentors and develops new quality/ regulatory managers and directors; Covers immediate regulatory activities for open quality/regulatory facility positions.
  • Conducts survey activities to include coordinating, directing, and supporting regulatory survey activities for MHS in collaboration with department directors and MHS Senior Management staff. Organizes and coordinates QRS/TJC surveys (including scheduling rooms, food, A/V, etc.). Serves as the liaison/point of contact for system to regulatory agencies and surveyors. Conducts survey preparation and follow up after survey reports (including unannounced survey activity). Authorizes / reviewing correspondence between MHS and regulatory agencies and HCA regarding regulatory activity/actions. Prepares correspondence and maintains records relating to regulatory surveys for MHS facilities.
  • Responsible for Program Administration including the coordination of accreditation and regulatory standards for the MHS and establishing and implementing processes to support ongoing compliance and survey readiness. Submits applications, license renewals, etc and provides communication updates and feedback to MHS Leadership regarding regulatory compliance issues.
  • Serves as an organizational resource for regulatory concerns and consultant to assist in achieving and maintaining regulatory compliance by providing interpretation, information, education and tools to Senior Leadership, Department Directors, and Quality/Risk/Regulatory Directors/Managers. Collaborate with hospital/department teams and individuals focused on regulatory compliance and provide to various hospital teams accurate and timely feedback and research findings on state and federal regulations. Interfaces and works collaboratively with Infection Control, Risk Management, Quality, Nursing, Operations, and other MHS directors. Updates and maintains personal knowledge of regulatory standards and issues by anticipating new regulations and presenting a strategy for compliance. Takes a leadership role in policy management and implementation.


What qualifications you will need:

  • Bachelor’s Degree in nursing or related field from an accredited program.
  • Master’s degree preferred.
  • 2 years of previous related experience in healthcare regulatory compliance.
  • 3-5 years of previous related experience in healthcare regulatory compliance is preferred.
  • Certified Joint Commission Professional (CJCP) is preferred.


Methodist Healthcare is recognized as the most respected and preferred healthcare provider in the South Texas region. As San Antonio’s second largest private employer, we employ more than 11,000 individuals, including 2,700 physicians in all specialties. Methodist Healthcare is a 50-50 co-ownership between Methodist Healthcare Ministries of South Texas, Inc. and HCA Healthcare. Since 1963, our commitment has never wavered in consistently improving the health and wellness of our community by “Serving Humanity to Honor God.”


Our network of greater San Antonio hospitals includes nine acute care facilities: Methodist Hospital, Methodist Children's Hospital, Methodist Hospital Ambulatory Surgery, Methodist Hospital Metropolitan, Methodist Hospital Northeast, Methodist Hospital South, Methodist Hospital Specialty and Transplant, Methodist Hospital Stone Oak and Methodist Hospital Texsan.  We also offer 4 freestanding emergency centers in Boerne, Converse, Westover Hills, and the Quarry. At each of our facilities, we offer an outstanding selection of doctors, healthcare professionals, equipment and health services from wellness events to transplant services, pediatrics, dermatology, cardiology, oncology and a complete range of other medical services.  For more information, please visit our website at www.sahealth.com.


If you find this opportunity compelling, we encourage you to apply. We promptly review all applications. Highly qualified candidates will be directly contacted by a member of our team. We are actively interviewing so apply today!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.



Our Company’s recruiters are here to help unlock the next possibility within your career and we take your candidate experience very seriously. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Gmail or Yahoo Mail. If you feel suspicious of a job posting or job-related email, let us know by clicking here.

For questions about your job application or this site please contact HCAhrAnswers at 1-844-422-5627 option 1.

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