Accreditation and Regulatory Compliance Manager

About the position Regions Hospital is seeking an experienced, resilient, and adaptable leader to oversee 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 all 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 continuous readiness. Additionally, this leader will develop 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 related 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 related 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 develop clear action plans and oversee their implementation
• Monitor and validate ongoing compliance readiness of the organization
• Successfully demonstrated ability to lead large scale projects and utilize performance improvement methods such as Lean or Six Sigma
• Ability to effectively communicate with individuals from all disciplines and all 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 complex 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.

Nice-to-haves

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

Benefits

• medical and dental insurance (which begin 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 Resilience that provides support and evidence-based practices to bring relief and build resiliency

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