Program Manager – Compliance (Healthcare)

Expleo•Minneapolis, MN

3d•$103,000 - $113,000•Hybrid

About The Position

This is a unique opportunity to shape compliance strategy, lead accreditation success, and influence patient safety and quality outcomes at scale. The Program Manager – Compliance will play a critical role in advancing regulatory excellence across hospital and affiliated care settings. The role involves leading high-impact initiatives and driving compliance strategy to ensure continuous readiness for major regulatory bodies such as The Joint Commission (TJC) and CMS. It offers enterprise-level visibility, presenting insights, risks, and recommendations directly to executive leadership. The position also focuses on applying Lean, Six Sigma, and PDSA methodologies to optimize compliance programs and outcomes within a collaborative culture committed to high reliability and continuous improvement.

Requirements

5–7 years of experience in healthcare compliance, accreditation, quality, or program management
2+ years of experience leading or supporting TJC accreditation processes, regulatory surveys, or healthcare compliance programs
Strong expertise in TJC, CMS (Conditions of Participation), MDH, and related regulatory requirements
Proven ability to lead accreditation efforts and regulatory surveys
Experience conducting risk assessments, compliance gap analyses, and corrective action planning
Knowledge of OSHA, building, and fire safety codes
Demonstrated success leading cross-functional, large-scale compliance or quality initiatives
Strong analytical skills with the ability to translate complex data into actionable insights
Experience building tracking tools, dashboards, and reporting frameworks to monitor compliance performance
Exceptional communication and influencing skills across all organizational levels
Ability to operate independently and partner effectively with multidisciplinary teams
Bachelor’s degree in Nursing, Healthcare Administration, Quality Management, or related field

Nice To Haves

Experience working across multiple healthcare entities or care settings
Lean or Six Sigma certification (Green Belt or Black Belt)
CPHQ, ASQ, or Certified Joint Commission Professional (CJCP) certification
Experience with electronic medical records (EMR) systems
Background in statistical analysis or healthcare data interpretation
Master’s degree in healthcare or business
Relevant certifications such as Lean, Six Sigma, CPHQ, ASQ, or CJCP

Responsibilities

Lead and support accreditation processes, including The Joint Commission (TJC) surveys and regulatory reviews
Serve as the organization’s subject matter expert (SME) for TJC standards, CMS Conditions of Participation, and related regulatory frameworks
Drive continuous regulatory readiness through proactive risk identification, mitigation strategies, and compliance monitoring programs
Lead end-to-end survey readiness and execution, directing all activities to ensure successful accreditation outcomes
Conduct gap assessments, assign risk levels/criticality, and implement corrective action plans
Establish and manage a regulatory surveillance function to track, interpret, and operationalize changes from CMS, MDH, and other governing bodies
Collaborate with clinical, operational, and administrative stakeholders across hospital and affiliated services (e.g., homecare, hospice, infusion, and specialty programs)
Support policy development, alignment, and staff education/training to ensure compliance with evolving regulations
Facilitate and lead on-site surveys, internal audits, and readiness reviews
Analyze performance and compliance data to identify trends and drive decision-making
Utilize Lean, Six Sigma, or PDSA methodologies to improve processes and regulatory outcomes
Develop dashboards, tracking tools, and executive-level presentations