Washington University of St. Louis Faculty Practice Plan in St. Louis, Missouri

Job Type/Schedule

This position is full-time and works approximately 40 hours per week.

Department Name/Job Location

This position is in the Department of the Faculty Practice Plan. This position is for the Medical School Campus.

Essential Functions


Position will be responsible for the development, implementation and sustainment of centralized policies at the Faculty Practice Plan (FPP) level. Position has primary oversight of regulatory compliance/ accreditation, primarily in the ambulatory care setting, in collaboration with all Washington University School of Medicine Clinical Departments. This position requires an individual with significant regulatory and compliance experience and who thrives on program development from early concepts to full implementation; this position also requires professional confidence, sound judgment, and experience as a process and change leader.


  1. Creates exceptional clinical outcomes and patient safety using knowledge of all regulatory body and state licensure standards and/or regulations; uses tracer, audit and tracking tools to monitor all CMS Conditions of Participation and other regulatory requirement standards on a rotating basis throughout the year; identifies areas of high risk for more intense monitoring and intervention.
  2. Serves as primary point of contact for WUSM for inquiries by regulatory and accreditation bodies; Works collaboratively with hospital partners to assist with inquiries by regulatory and accrediting bodies when both parties are involved.
  3. Develops and monitors implementation of policies, procedures, and regulatory plans within all Washington University School of Medicine Clinical Departments.
  4. Reviews available quality and patient safety data to identify areas of high risk for deviation from standard and need for policy implementation; develops action plans to correct deficiencies through policy implementation or modification as appropriate. Implementation and monitoring of those plans.
  5. Conducts debriefs and root cause analyses in collaboration with WUSM Clinical Departments on known departures from CMS COPs and other standards, with development and monitoring of appropriate action plans.
  6. Works collaboratively through-out organization to educate clinical leaders on changes in standards and policies; incorporates changes into the regulatory compliance/ accreditation program.
  7. In coordination with the Patient Safety & Quality staff, monitors opportunities for improvement and sentinel event reports to focus on high risk areas that may negatively impact standards compliance.
  8. Responsible for developing and maintaining a continuous readiness program that encompasses all the necessary elements to maintain regulatory compliance; reviews the integrity of the program over time, reporting concerns and barriers to compliance to leadership.
  9. Participates in rounding to engage with caregivers and front line staff responsible for meeting standards and policy compliance.
  10. Coordinates regulatory and survey activity (i.e. CMS, state and/or mock survey activity).
  11. Maintains a working knowledge of emerging regulatory and accreditation initiatives across Washington University School of Medicine and develops close working relationships with their program/clinical representatives.
  12. Assists with WUSM Patient Safety, Quality and Performance Improvement initiatives as needed, at the direction of FPP leadership.

Required Qualifications

Master’s degree in a healthcare-related field required; current RN licensure in the state of Missouri required; knowledge of state and federal regulations specific to healthcare compliance and/or accreditation.

Preferred Qualifications

  • 5 to 10 years of relevant work experience in regulatory or compliance setting; experience in program development in quality measurement and/or improvement or patient safety and/or compliance/ accreditation; experience working in large, complex healthcare organization; certification in the area of healthcare compliance or accreditation.
  • Superior data management and analytic skills; superior organizational and interpersonal skills, very strong Microsoft Office skills, including Excel, PowerPoint, and Word; ability to design, develop, and present refined spreadsheets, reports, white papers, and slide presentations; confidence and comfort in working in a largely independent role; strong project management skills with experience in planning, facilitating, and organizing improvement teams; extreme degree of professionalism, discretion, and confidentiality; comfort interacting with and publicly presenting to with a broad array of administrative and clinical staff, including senior management; experience with performance improvement methods, including statistical concepts, applications and data collection.

Salary Range

The hiring range for this position is commensurate with education and experience.


  • Retirement Savings Plan

  • 22 vacation days

  • 8 Paid Holidays

  • Sick Time

  • Tuition benefits for employee, spouse and dependent children

  • Free Metro Link/ Bus pass

  • Free Life Insurance

  • Health, Dental, Vision

  • Health Savings Accounts (HSA)

  • Long Term Disability Insurance

  • Flex Spending Plan

  • Other Benefits

Med School HR website (medschoolhr.wustl.edu)

EOE Statement

Washington University is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity or expression, national origin, genetic information, disability, or protected veteran status.

Job Title: Director, Compliance Accreditation - Faculty Practice Plan - 41528

Job ID: 41528

Location: Medical School

Full/Part Time: Full-Time

Regular/Temporary: Regular