Regulatory Compliance Director

Location US-IN-Indianapolis
Job ID
Facilities Management
Company Name


Medxcel is here to lead the transformation of healthcare facilities management by incorporating a new approach to providing services. Created by healthcare, for healthcare, we have a dedicated focus on our people and customers, as well as providing tools, processes, support resources, data analytics and insource strategies that drive results.


This is a high travel position.


The Regulatory Compliance Director provides expert consultation, education, and technical assistance to Medxcel’s operations and healthcare facilities in complying with the Authority Having Jurisdiction (AHJ) Standards and Programs for Medxcel throughout the assigned working location within our Central Office - Indianapolis, INThis position is eligible to work in any Medxcel operating state. 


  AHJ’s to include: The Joint Commission (TJC)-Physical Environment (PE), CMS-Conditions of Participation, OSHA, States Department of Health, etc. This position will provide regulatory guidance to Compliance Support Teams, Medxcel Safety, and Facility Operations Teams. The Regulatory Compliance Director will utilize Medxcel’s tools to conduct mock surveys, Tracer Reviews, and assessing standards compliance. The position will provide the regulatory expertise in supporting Medxcel’s Facility Management Operating Systems (FMOS), assessing new and existing business for regulatory compliance and provide input into Medxcel’s monthly newsletter concerning compliance excellence. The position supports the sales process by assisting with PE/FM compliance analyses in the development of sales proposals.       



Leadership, Coaching, and Development 

  • Provide strong leadership particularly in the areas of patient safety, patient experience, regulatory compliance, risk reduction, performance metrics, work process efficacy and efficiency, team performance, and the pursuit of excellence utilizing Medxcel programs
  • Facilitate the creation of a professional practice environment that promotes excellence in patient centered care and provides for positive patient outcomes
  • Provide leadership and direction for TJC accreditation process and ensure compliance with other regulatory requirements; facilitate and promote organizational regulatory readiness and compliance according to the requirements of the AHJ
  • Provide guidance to teams for program creation and delivery
  • Work effectively with Medxcel executives and other leaders to drive business innovation, service strategies, revenue growth, and continuous improvement processes at the regional level to ensure service excellence
  • Leverage local and regional professional society involvement as a means of promoting and representing Medxcel within regions or local communities through pre-defined branding and service initiatives


Operational Support Management

  • Ensure regulatory updates from TJC, CMS, and State Department of Health are disseminated to leaders and teams appropriately
  • Provide education and training to Executive and Clinical Leadership concerning changes in requirements for accreditation and licensure
  • Evaluate the effectiveness of quality programs/processes against standards of practice, protocols, and patient outcome measurements
  • Create action plans to ensure regulatory compliance for new and existing Medxcel business units
  • Work with the Vice President of Program Development and Facilities Compliance to transition Medxcel’s policies and operational procedures to hospital associates
  • Provide support for corporate wide and regional strategic initiatives as assigned
  • Support the sales process by assisting with operational and regulatory analyses and by providing technical support in the development of service proposals
  • Hold full accountability for achieving service excellence, regulatory compliance, and organizational development goals
  • Create a high performing team of on-site leaders through selecting and retaining the best individuals possible and appropriately holding this team accountable for their areas of responsibility


Compliance Management 

  • In collaboration with the Vice President of Program Development and Facilities Compliance, provide oversight and direction to the Physical Environment program
  • Provide support to client organizations in reviewing complaints from the state and/or federal government and advising organizations accordingly; develop an action plan as a result of deficiencies cited due to a complaint, focus, or validation survey
  • Perform mock surveys, Tracer Reviews, Life Safety and Safety Assessments of healthcare facilities as part of the compliance process; develop action plans to remediate issues identified as areas of improvement
  • Perform in-depth quality reviews of site operations using the tools provided by Medxcel and facilitate on-going plans, goals, and objectives, to correct deficiencies and improve performance
  • Lead the team of on-site associates emphasizing the compliance of Medxcel’s operational program, FMOS, to enable on-site leaders to succeed



  • Bachelor’s degree in Engineering, Fire Protection Engineering, Fire Science Technology OR 15+ years’ relevant experience in lieu of degree                         
  • Master’s degree in related discipline preferred




  • Certified Healthcare Facilities Manager (CHFM) and/or Certified Healthcare Safety Professional (CHSP) certification preferred




  • 10+ years of recent experience in health care, with 7-10 years of progressively increased responsibilities in senior healthcare management or demonstrated consulting expertise
  • Experience with the Joint Commission’s Physical Environment and CMS’s Conditions of Participation
  • Experience with NFPA 101 Life Safety Code and other National Fire Protection Agency (NFPA) requirements                           
  • Experience in deploying service programs preferred


Knowledge, Skills and Abilities:

  • Working knowledge of hospital facilities management operations and hierarchy of leadership
  • Working knowledge of facility systems and equipment
  • Maintain current knowledge of Joint Commission Environment of Care standards including the Life Safety Code© (NFPA 101) and other relevant NFPA standards and requirements
  • Ability to clearly link deficient practices with related CMS regulations and TJC standards with potential system vulnerabilities and related organization risk points
  • Project management skills including coordination, communication, prioritization, troubleshooting, and completion goals
  • Excellent communication and interpersonal skills with ability to communicate across all levels of the organization, including technology, tools, and processes
  • Problem solving — identifies and resolves problems in a timely manner and gathers and analyses information skillfully
  • Planning/organizing — prioritize and plan work activities, use time efficiently, and develop realistic action plans
  • Ability to adapt – adapt quickly to changes in scope or direction and be flexible to adopting changes quickly
  • High level of motivation and the ability to work in a fast-paced environment with little supervision
  • Ability to work on multiple projects in a matrix team environment
  • Must professionally represent the organization, while obtaining collaborative results
  • Proficient in MS Office Suite (Excel, Word, Access, and PowerPoint)
  • Strategic leadership skills to execute initiatives and objectives
  • Ability to be sensitive to and respectful of all internal and external stakeholders and customers without compromising in any way on the message that must be delivered
  • Keen business acumen with the ability to effectively influence and collaborate with stakeholders of all levels (frontline to C-Suite) within ministry/client organizations
  • Open to direction, inquiry, and idea exchange
  • Negotiation skills
  • Travel: 50-75% (overnight travel required) with access to a major airport



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