Program Manager, Accreditation and Regulatory Compliance
About The Position
Leads the organization’s accreditation and regulatory compliance program, ensuring compliance with applicable laws, standards, and government regulations. Serves as an independent and objective body that reviews and evaluates compliance issues and concerns. Provides leadership to align operations with federal, state, and accrediting-body requirements, including those of the Centers for Medicare & Medicaid Services and The Joint Commission. Oversees regulatory risk and survey-readiness strategy in alignment with system accreditation, regulatory, and licensing priorities. Designs, implements, and optimizes the site’s regulatory program to support continuous survey readiness, successful accreditation outcomes, and sustained compliance. Ensures the Board of Directors, senior management, and employees comply with regulatory requirements and organizational policies and procedures. Manages regulatory compliance through comprehensive assessments of organizational practices. Supervises and directs assigned personnel using professional and supervisory discretion and independent judgment, and manages large programs with substantial budget or impact. The role reviews and interprets regulatory standards, maintains compliance documentation, conducts audits and investigations, and develops risk-management strategies. It designs systems for continual regulatory, licensure, and accreditation compliance; coordinates survey preparation and on-site surveys; trains employees; assists auditors; prepares compliance reports; and develops responses and action plans for regulatory citations. The role also reviews unusual occurrences and adverse events, partners on related reports, and ensures corrective actions are taken to protect patient safety and regulatory compliance.
Requirements
- Bachelor’s degree in nursing, business administration, hospital administration, or an equivalent combination of education and related experience.
- Three years of experience in healthcare.
- Five years of experience in healthcare accreditation and regulatory affairs, with two years of leadership experience in Accreditation and Regulatory.
- CPHQ, HACP, or Lean certification required within two years of hire.
- Receive all required vaccinations as a condition of employment and annually thereafter, where applicable; medical and religious exemptions may apply.
Nice To Haves
- Two years of experience in accreditation, regulatory compliance, or process improvement.
Responsibilities
- Review, interpret, and assist hospital departments, leadership, and Medical Staff with implementing federal, state, and Joint Commission standards and regulations.
- Maintain and control regulatory, licensure, and accreditation documents, and monitor compliance with Joint Commission standards.
- Conduct periodic internal reviews and audits to ensure compliance procedures are followed.
- Identify regulatory compliance issues requiring follow-up or investigation and manage internal investigations of compliance issues.
- Review operational risks and develop risk-management strategies.
- Disseminate written policies and procedures related to regulatory compliance activities.
- Design and implement systems for continual regulatory, licensure, and accreditation compliance.
- Support accreditation preparation by managing logistics, conducting mock surveys, and communicating regulatory changes and updates.
- Provide employee training on regulatory compliance topics, policies, and procedures.
- Assist internal and external auditors with regulatory compliance reviews.
- Prepare reports on regulatory compliance operations and progress, and monitor compliance systems for effectiveness.
- Provide direction and assure regulatory compliance; coordinate on-site regulatory, licensure, and accreditation surveys, organize schedules, and conduct internal audit processes.
- Conduct an annual state regulatory compliance assessment and develop and maintain action plans and responses to regulatory citations.
- Collect data, prepare graphic presentations, and compile reports demonstrating compliance.
- Prepare and submit reports following reviews of unusual occurrences and adverse events in partnership with a network manager or network director; alert regulatory bodies as required.
- Review unusual occurrences and adverse events and ensure immediate corrective actions are implemented for reportable events to safeguard patient safety and regulatory compliance.
- Supervise and direct assigned personnel.
- Perform other job-related duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
