Program Manager-Regulatory Readiness

Hospital Sisters Health System • Green Bay, WI

1d • $38 - $57 • Onsite

About The Position

Hospital Sisters Health System (HSHS) is seeking a Program Manager-Regulatory Readiness to join our team. The Program Manager-Regulatory Readiness is responsible for ensuring the hospital maintains continuous compliance with all applicable regulatory, accreditation, and certification standards [e.g., The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), state Department of Health, Occupational Safety and Health Administration (OSHA)]. This role partners with hospital leaders, frontline staff, and quality teams to sustain a culture of readiness, lead survey preparation activities, monitor ongoing compliance, and mitigate risk. This role serves as a subject matter expert, guiding the organization through regulatory requirements, leading mock surveys, coordinating improvement initiatives, and ensuring compliance is integrated into daily operations across all departments.

Requirements

• Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or related field is required.
• 5 years of healthcare experience is required, including at least 3 years in regulatory, quality, accreditation, or compliance roles.
• Experience with The Joint Commission, CMS, and state survey processes is required.

Nice To Haves

• Master’s degree in Nursing, Healthcare Administration, or related field is preferred.
• Leadership or project management experience is preferred.
• Experience with hospital operations, clinical care delivery, and regulatory frameworks is preferred.
• Certification in healthcare quality, compliance, or patient safety is preferred (e.g., Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS), Certified in Healthcare Compliance (CHC), Healthcare Accreditation Certified Professional (HACP).

Responsibilities

• Ensuring the hospital maintains continuous compliance with all applicable regulatory, accreditation, and certification standards
• Partnering with hospital leaders, frontline staff, and quality teams to sustain a culture of readiness
• Leading survey preparation activities
• Monitoring ongoing compliance
• Mitigating risk
• Guiding the organization through regulatory requirements
• Leading mock surveys
• Coordinating improvement initiatives
• Ensuring compliance is integrated into daily operations across all departments

Benefits

• HSHS provides a benefits package designed to support the overall well-being of our colleagues including their physical, emotional, financial, spiritual, and work health.
• Colleagues budgeted to work at least 32 hours per pay period are eligible for HSHS benefits.
• Comprehensive and affordable health coverage includes medical, prescription, dental and vision coverage for full-time and part-time colleagues.
• Paid Time Off (PTO) combines vacation, sick, and personal days into one balance to allow you the flexibility to use your time off as you need.
• Retirement benefits including HSHS contributions.
• Education Assistance benefits include up to $4,000 of educational assistance each calendar year and tuition discounts to select colleges with no waiting period.
• Adoption Assistance provides financial support up to $7,500 for colleagues growing their families through adoption to reimburse application and legal fees, transportation, and more!
• Other benefits include: Wellness program with incentives, employer-paid life insurance and short-term and long-term disability coverage, flexible spending accounts, employee assistance program, ID theft coverage, colleague rewards and recognition program, discount program, and more!

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 501-1,000 employees