Accred/Regulatory Program Manager

Duke University • Mooresville, NC

77d

About The Position

The Accreditation and Regulatory Program Manager position is responsible for collaborating, at a system/entity level, with leadership, staff and medical staff to provide a proactive, global and unified perspective and understanding of accreditation, regulatory and disease specific certification requirements and activities. The Accreditation and Regulatory Program Manager is a systems thinker playing a pivotal role in leading system/entity efforts to achieve the highest compliance with accreditation and certification standards with an approach to ensuring practices not only meet but exceed benchmarks for patient care excellence. This role collaborates in shaping and supporting the framework for ongoing accreditation success, by leveraging extensive knowledge in regulations, standards and improvement methodologies. The position serves the system/entity organization as a resource, mentor, and educator for regulatory, accreditation and certification programs; working across the organization to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes. The Accreditation and Regulatory Program Manager collaborates with system/entity operational, executive and medical staff leadership to operationalize an effective continuous readiness infrastructure that ensures and sustains the DUHS Accreditation and Regulatory Program goals of 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations. This role includes programmatic ownership of Accreditation and Regulatory activities, ensuring strategic alignment and execution of related initiatives.

Requirements

• Bachelor's degree in Nursing, Business, Healthcare Administration; Master's degree preferred.
• 5 years of experience in accreditation, certification, quality, risk management, patient safety or clinical operations.
• 2 years of healthcare/medical/nursing/patient care experience preferred.
• Knowledge of quality improvement methodologies, project management and regulatory standards.
• Ability to work on-site for unannounced surveys.

Nice To Haves

• Management experience in clinical operations.
• Experience with auditing/data analytics.
• Experience with project management systems.
• Previous accreditation readiness experience.

Responsibilities

• Lead continuous readiness efforts by evaluating, planning and supporting compliance and readiness infrastructure.
• Support workflow needs and develop strengths of content experts and leadership.
• Collaborate with various departments to ensure regulatory functions are compliant with standards.
• Identify accreditation or regulatory risks and support operational leaders in improvement processes.
• Manage system/entity-wide accreditation and regulatory compliance initiatives.
• Provide guidance on accrediting and certification standards interpretation.
• Establish processes for ongoing proactive review of regulatory standards.
• Develop initiatives to monitor compliance with regulatory standards.
• Participate in pre-survey, on-site survey and post-survey activities.
• Conduct internal surveys to assess ongoing survey readiness.
• Develop toolkits, education materials and provide educational opportunities.
• Ensure regulatory resources are up to date.
• Serve as a contact for standards-related manuals and educational materials.
• Enhance continuous improvement activities through performance improvement methodologies.
• Coordinate accreditation, regulatory or certification surveys.
• Collaborate with leadership to develop corrective action plans.

Benefits

• Comprehensive range of medical services.
• Opportunities for professional development.
• Supportive work environment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Educational Services
• Education Level: Bachelor's degree