Manager of Regulatory & Emergency Management

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 Commission standards, 

CMS Conditions of Participation, OSHA 

standards, High Reliability Organization 

principles, and emergency preparedness 

regulations.

La Rabida Children’s Hospital is very proud to be an Equal Employment Opportunity Employer

La Rabida is a place unlike any other. We understand the needs of families with children dealing with the most serious or complicated of conditions. With teams of the best healthcare providers in Chicago, we give continuous, comprehensive care, education, and support, helping families face their unique obstacles head-on.   

La Rabida Children’s Hospital is very proud to be an Equal Employment Opportunity Employer.