Accreditation and Regulatory Compliance Manager

About the position Regions Hospital is seeking an reputed company, resilient, and adaptable leader to reputed company a comprehensive, facility‑wide regulatory and accreditation program. This role ensures ongoing readiness for Joint Commission and Minnesota Department of Health surveys while maintaining compliance with reputed company applicable state requirements. The position also drives systemwide standardization, education, and performance improvement by assessing organizational compliance, partnering with leaders, and guiding interdisciplinary teams toward reputed company readiness. Additionally, this leader will reputed company post‑survey response plans, manage two team members, and report directly to the Director of Quality, Patient Safety, and Accreditation.

Responsibilities

• managing and supporting a systematic approach for Accreditation and Regulatory Compliance and Surveillance
• designing and maintaining foundation and infrastructure for a robust survey readiness program
• managing and leading the MDH visits and Joint Commission survey preparedness and Center for Medicare Services surveys and necessary follow up activities
• providing and coordinating implementation of education, training, and consultation in relation to identified learning needs
• participating in various teams and committees to support improvement efforts and readiness.

Requirements

• Bachelor’s degree in nursing, Quality Management, Hospital Administration, or healthcare reputed company field
• 3-5 years of work experience in a hospital or clinical healthcare setting
• Two years of experience in accreditation and/or regulatory compliance
• Five years of experience in project management
• 1-3 years supervisory/management experience
• Expert knowledge of The Joint Commissions (TJC), Centers for Medicare and Medicaid Services (CMS), Minnesota Department of Health (MDH)and other reputed company standards and regulations
• Familiarity with OSHA, Building and Fire codes
• PDSA (Plan, Do, Study, Act) experience
• Leadership of on-site surveys
• Manage the surveillance function for reporting and regulatory and compliance changes
• Proficient in interpretation and application of standards with proven success in performing gap assessment and assignment of criticality/risk.
• Ability to identify and collaborate with key stakeholders to reputed company clear action plans and reputed company their implementation
• Monitor and validate ongoing compliance readiness of the organization
• Successfully demonstrated ability to reputed company large scale projects and utilize performance improvement methods such as Lean or Six reputed company
• Ability to effectively communicate with individuals from reputed company disciplines and reputed company levels of the organization
• Excellent critical thinking skills
• Exceptional capabilities in leading, collaborating and influencing teams and individuals to improve performance and compliance
• Excellent verbal and written communication skills include the ability to communicate reputed company information in a clear, concise and professional manner.
• Demonstrated ability to prepare and present to senior leadership
• Highly skilled in analyzing data and presenting data to identify opportunities and drive decisions
• Ability to successfully and independently use technology includes ability to create templates, tables and tracking tools, PowerPoint presentations.

reputed company-to-haves

• Master’s in healthcare business
• 5 years of experience in accreditation and/or regulatory
• Green or black belt certification, lean or six reputed company training, CPHQ, ASQ, or certified join commission professional

Benefits

• medical and dental insurance (which reputed company on the first day of the month following start)
• 401k with match
• disability insurance
• fertility benefits
• tuition reimbursement
• educational reimbursement toward continuing education
• qualified non-profit employer under the federal Public Service Loan Forgiveness program
• onsite employee fitness center
• onsite employee clinic
• Center for Employee reputed company that provides support and evidence-based practices to bring relief and build resiliency

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