Registered Nurse (RN) Program Manager Accreditation and Regulatory

Duke Careers • Durham, NC

123d

About The Position

The Accreditation and Regulatory Program Manager is responsible for collaborating, at a system/entity level at Duke University Hospital and Duke Raleigh Hospital, A Campus of Duke University Hospital, with leadership, staff, and medical staff to provide a proactive, global, and unified perspective on accreditation, regulatory, and disease-specific certification requirements and activities. This position plays a pivotal role in leading efforts to achieve the highest compliance with accreditation and certification standards, ensuring practices not only meet but exceed benchmarks for patient care excellence. This role supports a continuous readiness infrastructure by leveraging deep regulatory knowledge and improvement methodologies. The manager acts as a resource, mentor, and educator for regulatory and accreditation programs, working across the organization to assess, measure, and report compliance; promote best practices; and standardize survey processes. In collaboration with operational, executive, and medical leadership, this role ensures alignment with the DUHS Accreditation and Regulatory Program goals: Standard Interpretation, Standard Compliance, Education and Communication, Survey Operations.

Requirements

• Bachelor's degree in Nursing, Business, or Healthcare Administration required.
• 5 years of experience in accreditation, certification, quality, risk management, patient safety, or clinical operations.
• 2 years of healthcare/patient care experience preferred. RN experience preferred.
• Knowledge of quality improvement methodologies, project management, and regulatory standards (NCQA, TJC, AAAHC, CMS, DNV).
• On-site presence required for unannounced survey readiness.

Nice To Haves

• Master’s degree preferred.
• Clinical operations experience, data analytics, training, accreditation readiness, and project leadership.
• RN strongly preferred or other licensed clinical professional preferred.
• Preferred certifications include: CPHQ, HACP, CJCP.

Responsibilities

• Drive proactive compliance and readiness infrastructure for accreditation and certification.
• Collaborate with departments such as Patient Safety, Quality, Risk, Legal, and more to assess compliance.
• Identify and mitigate regulatory risks in partnership with leadership.
• Lead accreditation and regulatory compliance initiatives and track corrective actions.
• Guide interpretation of standards and requirements.
• Support and conduct internal assessments (e.g., tracers, mock surveys).
• Analyze and report survey trends; implement risk reduction activities.
• Update policies and develop education tools based on findings.
• Create toolkits, presentations, and reference materials.
• Maintain regulatory resources (e.g., AMP, CMS guidelines).
• Conduct education sessions and support policy alignment with standards.
• Provide support for accreditation/regulatory bodies.
• Monitor updates in regulations and disseminate relevant information.
• Support continuous improvement through LEAN, PDCA, DMAIC methodologies.
• Partner with leadership on implementing policy improvements.
• Develop and coordinate entity-specific unannounced survey plans.
• Co-manage on-site surveys and logistics.
• Support communication, agendas, and real-time coordination.
• Guide development of corrective actions in response to findings.
• Monitor progress and sustain improvements.
• Ensure timely submission of required documentation.
• Conduct follow-up internal surveys and report on implementation outcomes.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees