Manager, Accreditation & Regulatory Compliance

Healthcare Accreditation & Regulatory Compliance Manager Healthcare | Regulatory Compliance | Accreditation | Quality & Patient Safety About the Role A healthcare organization is seeking a Healthcare Accreditation & Regulatory Compliance Manager to lead accreditation, regulatory compliance, licensing, and survey-readiness activities across an assigned hospital or healthcare market. This role is responsible for maintaining continuous readiness for regulatory surveys and ensuring compliance with CMS, The Joint Commission, state requirements, and other applicable healthcare regulations . The position works closely with clinical, operational, quality, risk, nursing, and medical staff to identify compliance gaps, implement corrective actions, and strengthen regulatory processes. Key Responsibilities Lead day-to-day accreditation, regulatory compliance, licensing, and survey-readiness activities. Coordinate internal audits, mock surveys, tracer programs, and regulatory assessments. Monitor compliance with federal, state, accreditation, and healthcare regulatory requirements. Develop, implement, and monitor corrective action plans following audits, surveys, and regulatory findings. Lead regulatory investigations and ensure appropriate follow-up and documentation. Partner with clinical and non-clinical departments to integrate regulatory requirements into policies, procedures, and workflows. Provide education and guidance to leaders and staff regarding accreditation and regulatory standards. Maintain accreditation, licensing, and regulatory documentation and reporting systems. Prepare reports and regulatory submissions related to unusual occurrences, adverse events, and compliance matters. Participate in root cause and apparent cause analyses and collaborate on risk-reduction initiatives. Work with Quality, Risk Management, Nursing, Medical Staff, and other departments on regulatory and patient-safety matters. Lead and develop a team of professionals responsible for accreditation, licensing, and regulatory compliance. Identify operational risks and recommend strategies to improve compliance and organizational performance. Monitor changes in healthcare regulations and accreditation standards and implement necessary updates. Requirements Bachelor's degree or equivalent combination of education and relevant experience. Master's degree preferred. 5+ years of healthcare or related experience preferred. 3+ years of experience in healthcare accreditation, regulatory compliance, quality, or process improvement. 2+ years of leadership or management experience preferred. Healthcare Accreditation Certified Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification, or ability to obtain within two years. Strong knowledge of healthcare accreditation, regulatory, licensing, and compliance requirements. Experience with regulatory audits, surveys, corrective action planning, and continuous readiness programs. Strong analytical, organizational, communication, and leadership skills. Function: Regulatory Compliance / Accreditation / Quality & Patient Safety #J-18808-Ljbffr SoTalent