Director of Accreditation and Licensure

Job Summary

The Director of Accreditation and Licensure provides organization-wide leadership and oversight for accreditation, licensure, and regulatory readiness across RiverValley & Affiliates. The Director serves as the organization’s primary subject matter expert for CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation and oversees applicable national accreditation and state licensure requirements across all programs and facilities in Kentucky, New Mexico, and North Carolina.

The position ensures continuous readiness by monitoring regulatory requirements, coordinating surveys and inspections, maintaining required documentation and renewals, identifying compliance gaps, and overseeing corrective action plans. Working collaboratively with executive, clinical, operational, Quality, Compliance, Legal, and other leaders, the Director integrates accreditation and licensure requirements into everyday operations and quality improvement efforts to support regulatory compliance, service quality, and organizational excellence.

Essential Functions

CARF Accreditation Strategy and Oversight

• Serve as the organization's primary point of contact and subject matter expert for CARF (Commission on Accreditation of Rehabilitation Facilities) and applicable CARF standards.
• Maintain a robust CARF readiness plan identifying applicable standards, responsible leaders, required evidence, monitoring activities, and corrective actions.
• Conduct or coordinate periodic CARF readiness assessments, mock surveys, tracer activities, documentation reviews to identify and close compliance gaps before CARF formal surveys.
• Prepare and submit all documentation, evidence, and materials required for CARF accreditation surveys.
• Coordinate the organization's response to CARF surveys, including on-site survey logistics, document preparation, staff scheduling, and support for surveyors during survey activity.
• Prepare and submit the organization's response to CARF survey findings, including development, submission, and tracking of the Quality Improvement Plan and any required corrective actions following the survey.
• Monitor changes to CARF standards and survey requirements and translate those changes into clear operational expectations for affected departments, programs, and leaders.
• Promote continuous CARF readiness throughout the accreditation cycle rather than episodic preparation immediately before surveys.

Additional National Accreditation Compliance

• Maintain working knowledge of additional national accrediting bodies applicable to the organization's facilities and service lines beyond CARF.
• Coordinate survey readiness, documentation, and response activities for all additional national accreditations held by the organization.
• Monitor changes to standards and requirements across all applicable national accrediting bodies and communicate impacts to affected facilities and departments.
• Maintain a comprehensive organization-wide calendar of accreditation surveys, licensure and certification renewals, regulatory submissions, corrective action deadlines, and other key compliance dates.

National and State Licensure Compliance

• Maintain expertise regarding applicable facility licensure, program certification, accreditation, and regulatory requirements in Kentucky, New Mexico, North Carolina, and other states in which the organization operates.
• Ensure timely preparation, submission, and renewal of applicable facility licenses, certifications, and regulatory filings, and coordinate or support certificate of need activities as applicable.
• Serve as primary liaison to state licensing and survey agencies and applicable national licensing or certification bodies, including coordination of surveys and follow-up visits.
• Evaluate accreditation, licensure, and certification requirements associated with new programs, service lines, locations, facility changes, acquisitions, and organizational expansion, and advise leadership regarding requirements prior to implementation.

Survey Readiness and Continuous Compliance

• Develop, review, and revise organizational policies, procedures, and supporting tools to ensure alignment with applicable accreditation, licensure, and regulatory requirements.
• Partner with clinical and operational leaders to review department-specific policies and identify required revisions based on changes in accreditation, licensure, or regulatory standards.
• Maintain a process for identifying changes to accreditation, licensure, and regulatory requirements; evaluating organizational impact; communicating changes to affected leaders; and monitoring implementation.
• Conduct regular internal audits and rounding to assess ongoing compliance with CARF, other applicable accreditation, and licensure standards.
• Partner with facility and department leaders to develop corrective action plans and monitor completion of remediation activities.
• Track and trend survey findings and internal audit results to identify systemic issues and recommend process improvements.

Education and Training

• Design and deliver training programs for clinical staff, department leaders, and executives on CARF standards, other applicable accreditation standards, licensure requirements, and survey readiness expectations.
• Develop orientation materials and ongoing education addressing regulatory and accreditation requirements applicable to job function.
• Serve as an internal resource and educator regarding evolving CARF, other national accreditation, and licensure requirements.

Collaboration with Corporate Compliance and Legal

• Promptly escalate significant, unresolved, or recurring accreditation and licensure risks to the Vice President of Medical Services and Compliance and other appropriate executive leaders.
• Support incident investigations, adverse event reviews, and sentinel event analyses from an accreditation and licensure perspective.
• Assist with responses to regulatory inquiries, complaint investigations, and government audits related to accreditation and licensure.

Documentation and Reporting

• Maintain organized, audit-ready documentation of CARF and other accreditation surveys, licensure filings, findings, and corrective actions for all facilities.
• Prepare regular reports on accreditation and licensure status, survey outcomes, and readiness metrics for executive leadership and Boards of Directors.
• Maintain accurate records of all accrediting body and licensing agency correspondence.

Required Knowledge, Skills, and Abilities

• Comprehensive knowledge of CARF accreditation standards applicable to behavioral health hospitals and outpatient behavioral health services.
• Working knowledge of additional national accreditation standards applicable to the organization's facilities and service lines.
• Strong working knowledge of national and state hospital and behavioral health licensing requirements.
• Ability to interpret complex regulatory and accreditation standards and translate them into practical operational requirements.
• Strong project management skills with the ability to coordinate survey readiness activities across multiple facilities and states.
• Excellent written and verbal communication skills, including the ability to prepare clear corrective action plans and regulatory submissions.
• Strong analytical skills with the ability to identify trends and systemic issues from audit and survey data.
• Ability to build collaborative relationships with clinical, operational, and executive leadership.
• Excellent presentation and training skills.
• Exceptional attention to detail, organization, and follow-through.
• Ability to manage multiple priorities and deadlines across a multi-state organization.

Required Qualifications

• Bachelor's degree in healthcare administration, nursing, public health, or related field required.
• Minimum of five years of progressively responsible experience in healthcare accreditation, licensure, quality, regulatory compliance, or a closely related function.
• Required CARF experience, including direct involvement in preparing for and responding to CARF accreditation surveys.
• Working knowledge of national and state hospital and behavioral health licensing regulations.
• Experience developing and delivering staff education and training programs.
• Strong organizational skills with the ability to manage multiple priorities independently.

Preferred Qualifications

• Master's degree in healthcare administration, nursing, public health, or related field.
• Experience with behavioral health hospital or multi-state hospital operations.
• Experience with additional national accrediting bodies (e.g., The Joint Commission, COA).
• Experience working with nonprofit healthcare entities.
• Familiarity with corporate compliance programs and government audits or investigations.

Physical and Environmental Requirements

• This position may require periodic travel to affiliated facilities in multiple states, including New Mexico and North Carolina, to support survey activities and accreditation/licensure functions, as well as occasional work outside normal business hours to address urgent survey or licensure matters. The position routinely handles confidential and sensitive information.