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Billings Clinic Director of Accreditation / Regulatory in Billings, Montana

You can make a difference as a part of our region's largest health care system, based locally in Billings, Montana. Join our amazing team with a focus on safe, high quality care and an excellent patient experience. Billings Clinic is here to take care of our community and region.

We look forward to meeting you.

About Us
Billings Clinic is a community-owned, not-for-profit, Physician-led health system based in Billings with more than 4,700 employees, including over 550 physicians and non-physician providers. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital. Learn more about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality.

Your Benefits
We provide a comprehensive and competitive benefits package to all full-time employees (minimum of 24 hours/week), including Medical, Dental, Vision, 403(b) Retirement Plan with employer matching, Defined Contribution Pension Plan, Paid Time Off, employee wellness program, and much more. Click here for more information or download the 2021 Employee Benefits Guide.

Magnet: Commitment to Nursing Excellence
Billings Clinic is proud to be recognized for nursing excellence as a Magnet?-designated organization, joining only 97 other organizations worldwide that have achieved this honor four times. The re-designation process happens every four years. Click here to learn more!

Director of Accreditation / Regulatory

QUALITY RESOURCES (Billings Clinic Main Campus)


Shift: Day

Employment Status: Full-Time (.75 or greater)

Hours per Pay Period: 1.00 = 80 hours(Exempt)

Starting Wage DOE

The Director of Accreditation / Regulatory is a recognized accreditation/regulatory expert within Billings Clinic and will work collaboratively with a variety of stakeholders in support of accreditation and regulatory standards and requirements. The postion is responsible for providing leadership and direction for the Accreditation/Regulatory Department and to ensure continuity and consistency across and throughout all areas of Billings Clinic, including branch locations. The Director provides leadership and direction for accreditation and regulatory standard requirements, addresses coordination and management of accreditation and regulatory readiness within Billings Clinic and the region, and is responsible for overall Accreditation/Regulatory Department budget and personnel management.

Essential Job Functions

• Develops and oversees Accreditation/Regulatory activities in alignment with the Billings Clinic mission, vision, values, strategic goals, and business objectives. Interprets and supports the mission and philosophy of Billings Clinic
• Responsible for the promotion of, and adherence to, the elements of Billings Clinic Code of Business Conduct and corporate compliance program as it relates to accreditation and regulatory standards and requirements
• In collaboration with Senior Leadership, physician leadership, other medical staff, and other health care providers:
• Develops, implements, and continuously evaluates accreditation and regulatory standards and requirements
• Develops Accreditation/Regulatory Departmental priorities and resource allocation
• Directs and oversees the development of programs to fulfill Billings Clinic initiatives relating to accreditation and regulatory standards and requir ements
• Facilitates processes for conducting internal process-based audits
• Assists Senior Leadership in understanding and prioritizing accreditation and regulatory initiatives within the organization
• Makes recommendations for utilization of internal or external consultants required to meet the needs of the Ready Every Day (RED) Team and Quality Management Oversight Committee
• Directs activities relating to the measurement, analysis, and reporting of internal process-based audits, non-conformities, and corrective actions from accreditation and regulatory surveys
• Develops recommendations based on accreditation and regulatory standards and requirements (DNV, CMS, etc.)
• Assists organization and individual business units in program development and determining service priorities that support accreditation and regulatory readiness
• Monitors accreditation and regulatory trends and developments at a national, regional and local level
• Ensures that Billing Clinic practices and procedures are aligned appropriately
• Evaluates Billings Clinic accreditation and regulatory readiness to identify deficiencies and opportunities for improvement
• Informs and assists Accreditation/Regulatory Department and Senior Leadership in identifying and capitalizing upon opportunities for improvement
• Directs the development of education and competency programs relating to accreditation and regulatory standards and requirements
• Practices process improvement principles to assess and improve the accreditation/regulatory readiness within the organization. • Works collaboratively with operational leaders, Risk Management, RED Team, Operational Excellence, and the Quality • Management Oversight Committee to identify and address areas for improvement
• Develops, retains, recruit s, and leads a talented management team committed to accomplishing the organizational/business unit goals, objectives and corporate compliance
• Recommends, implements, and evaluates plans and systems that assures sufficient number of qualified and competent staff to provide services
• Adheres to administrative policy/procedures relating to human resource management
• Demonstrates and encourages an ethic of open communication and teamwork throughout the organization. Builds an environment of shared commitment to Billings Clinic’s goals and responsibility to achieve accreditation and regulatory standards and requirements
• Leads evaluation, selection, and integration of technology and information management systems within Accreditation/Regulatory Department that supports an efficient use of resources
• Responsible for information management systems and the validation, quality and integrity of data utilized for statistical data, trending, and analysis for accreditation and regulatory standards and requirements
• Enterprise accountability for Accreditation/Regulatory:
• Billings Clinic and Regional Branches (Heights, West End, Bozeman, Cody, Miles City)
• Critical Access Hospital - Stillwater Billings
• Enterprise Oversight Responsibilities for the Accreditation/Regulatory programs at the Regional Care/ Joint Venture facilities, in concert with the Regional Care/ Joint Venture Leadership

Minimum Qualifications

4 Year Bachelor's Degree in a related field

6 Years of Leadership Experience
Certifications and Licenses

Bio-Met III Certification at hire
Billings Clinic is Montana’s largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more

Billings Clinic is committed to the principles of Equal Employment Opportunity. All policies and processes are designed toward achieving fair and equitable treatment of all employees and job applicants. Employees are encouraged to discuss any concerns they have in this regard with their immediate supervisor and/or the Vice President People Resources. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, creed, religion, national origin, gender, gender identity, sexual orientation, age, marital status, genetic information or disability.