Manager of Regulatory & Emergency Management

La Rabida Children's Hospital

Location: Chicago, United States

La Rabida Children’s Hospital provides specialized, family-centered health care to children with medically complex conditions, disabilities, and chronic illness. Through expertise, compassion, and advocacy we help children and their families reach their fullest potential, regardless of their ability to pay. Our not-for-profit hospital, licensed for 49 beds, helps transition children from neonatal or pediatric intensive care to home, by providing medical, rehabilitative and developmental care, and by training families to continue treatments and manage the necessary equipment in the home. La Rabida also provides extensive rehabilitation for those recovering from wounds or burns and treatment for exacerbations of chronic conditions. The hospital’s enhanced pediatric patient-centered medical home provides primary care to children with complex medical conditions and their siblings. Children with medical homes elsewhere come to La Rabida for specialty services. La Rabida offers a wide range of specialty services provided to children with sickle cell disease, diabetes, and many others. Children are supported in their emotional and developmental growth, particularly in cases where such growth has been interrupted by accident or disease. Finally, La Rabida provides forensic and treatment services for children exposed to abuse and neglect, comprehensive assessments for youth in care, early intervention for children between 0 and 3 years of age. Care coordination services for medically complex children are also provided for those who are covered by a health plan and receive care from providers in Cook County SUMMARY: The Manager, Regulatory and Emergency Management is responsible for the leadership, coordination, and oversight  of La Rabida Children's Hospital's regulatory compliance, accreditation readiness, licensure management, and  emergency preparedness programs. Reporting to the COO, this position promotes continuous readiness for  accreditation and regulatory surveys, supports patient safety and high reliability initiatives, and directs the hospital's  comprehensive emergency management program. The Manager serves as an organizational resource for regulatory standards, accreditation requirements, emergency  preparedness activities, and performance improvement initiatives. Working collaboratively with leaders, physicians,  employees, and external agencies, the position ensures ongoing compliance with regulatory and accreditation  requirements while strengthening organizational preparedness, resilience, and patient safety. ESSENTIAL FUNCTIONS: Regulatory Compliance & Accreditation Readiness • Direct and oversee the hospital-wide regulatory compliance and accreditation readiness program. • Ensure continuous compliance with The Joint Commission, CMS Conditions of Participation, Illinois  Department of Public Health requirements, and other applicable regulatory standards. • Lead planning, preparation, coordination, and follow-up activities for accreditation surveys, regulatory  inspections, and validation reviews. • Serve as the primary liaison for regulatory and accreditation agencies and coordinate organizational  responses to survey findings. • Oversee hospital licensure, certifications, permits, registrations, and required regulatory submissions. • Monitor regulatory changes and communicate new requirements to organizational leaders and stakeholders. Continuous Readiness, Assessment & Performance Improvement • Conduct regulatory rounds, tracers, mock surveys, environmental tours, audits, and gap assessments to  evaluate organizational compliance and readiness. • Review policies, procedures, clinical documentation, and operational practices to identify regulatory  vulnerabilities and opportunities for improvement. • Develop corrective action plans and monitor implementation to ensure sustained compliance. • Lead regulatory performance improvement initiatives utilizing evidence-based practices, risk reduction  strategies, and High Reliability Organization principles. • Analyze compliance findings, survey outcomes, and organizational data to identify trends, prioritize risks,  and support leadership decision-making. • Develop and maintain compliance dashboards, scorecards, reports, and readiness metrics. Emergency Management & Preparedness • Develop, implement, and maintain the hospital's Emergency Management Program and Emergency  Operations Plan (EOP). • Ensure compliance with CMS Emergency Preparedness requirements, The Joint Commission standards,  OSHA requirements, and applicable federal, state, and local regulations. • Conduct annual Hazard Vulnerability Analyses (HVA) and risk assessments to identify threats and  vulnerabilities and develop mitigation strategies. • Develop and maintain emergency preparedness policies, procedures, and response plans. • Coordinate emergency preparedness activities across all hospital departments to support organizational  readiness and resilience. • Manage emergency preparedness grants, programs, and reporting requirements as applicable. Training, Response & Community Coordination • Plan, facilitate, and evaluate emergency preparedness training, tabletop exercises, functional exercises, and  full-scale disaster drills. • Educate staff regarding emergency response procedures, Hospital Incident Command System (HICS) roles,  and individual responsibilities during emergencies. • Maintain the Hospital Incident Command System structure and support activation, response, recovery, and  after-action activities during emergency events. • Serve as the primary liaison with healthcare coalitions, public health agencies, emergency management  organizations, and community partners. • Coordinate emergency communications, surge planning, resource management, and continuity of operations  activities. • Lead post-event evaluations, corrective action planning, and after-action reporting to strengthen future  preparedness efforts. ADDITIONAL FUNCTIONS: • Participates in hospital committees, task forces, accreditation teams, and multidisciplinary workgroups. • Provides consultation and education to leaders and staff on regulatory compliance, accreditation standards,  and emergency preparedness requirements. • Assists with organizational initiatives related to patient safety, quality improvement, risk reduction, and  operational excellence. • Represents the hospital during external meetings, surveys, healthcare coalition activities, and emergency  preparedness events. • Performs other duties as assigned in support of organizational priorities.   Education: Bachelor's degree, Healthcare Administration, Public Health,  Emergency Management, Quality Management, or related  field required. Master's degree preferred. Related Work Experience: • Minimum five (5) years of progressive experience in  healthcare regulatory compliance, accreditation,  quality, patient safety, emergency management, or  related healthcare operations. • Experience leading accreditation surveys, regulatory  readiness programs, tracers, mock surveys, or  emergency preparedness activities required. • Experience in a hospital setting required. • Pediatric healthcare experience preferred. Licensure/Certification: • FEMA IS-100, IS-200, IS-700, and IS-800 preferred or  obtained within established timeframe. CPR required:None Required PALS required: None Required   Preferred Qualifications: • Certified Professional in Healthcare Quality  (CPHQ).  • Certified Professional in Patient Safety (CPPS).  • Certified Healthcare Emergency Professional  (CHEP), Certified Healthcare Emergency  Coordinator (CHEC), or Certified Emergency  Manager (CEM).  • Knowledge of Joint Commiss

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