Program Manager-Regulatory Readiness

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

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.

Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or related field is required.

Master’s degree in Nursing, Healthcare Administration, or related field is preferred.

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.

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).

In-depth knowledge of healthcare regulatory and accreditation standards, including The Joint Commission (TJC), CMS Conditions of Participation, and state/federal regulations.

Ability to analyze survey findings, identify root causes, and develop effective corrective and preventive action plans.

Strong leadership presence with the ability to coach, mentor, and engage leaders and staff across all levels to foster a culture of continuous readiness and accountability.

Proven ability to plan, organize, and execute large-scale readiness programs and survey preparation activities with attention to timelines, deliverables, and outcomes.

Exceptional written and verbal communication skills with the ability to clearly translate complex regulatory requirements into operational practices and provide effective training.

Demonstrated success working cross-functionally with clinical, quality, and administrative teams to drive compliance and performance improvement initiatives.

Strong ability to monitor compliance trends, use data-driven insights to improve performance, and proactively identify and mitigate organizational risk.

Leads the hospital’s continuous survey readiness program, ensuring ongoing compliance with all regulatory and accreditation standards.

Interprets and operationalizes regulatory requirements, translating standards from agencies such as TJC, CMS, and state health departments into actionable practices for leaders and staff.

Develops, implements, and monitors policies, procedures, and compliance practices to sustain a culture of readiness across all departments.

Maintains and oversees the hospital’s comprehensive regulatory readiness plan, including a calendar of compliance monitoring, rounding, and audit activities.

Plans, coordinates, and leads mock surveys and tracer activities, coaching staff and leaders to prepare for successful external surveys.

Serves as the primary on-site lead during accreditation and regulatory surveys, facilitating coordination with surveyors and ensuring a smooth, organized process.

Monitors, tracks, and reports survey findings and corrective actions, ensuring timely resolution and sustained compliance performance.

Collaborates with quality, safety, infection prevention, and clinical leaders to analyze compliance data, identify risks, and implement performance improvement initiatives.

Develops and delivers education and training programs on regulatory readiness, compliance expectations, and best practices for leaders and staff.

Communicates regulatory updates and mentors leaders to strengthen organizational accountability and promote continuous improvement in readiness and compliance.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Abides by all safety requirements including demonstrating proper hand hygiene and wearing of Personal Protective Equipment (PPE), if applicable. 

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline. Commits to keeping all patient, student or colleague information confidential and maintains ongoing communication and collaboration with team members. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other