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Hybrid Hospital Regulatory and Accreditation Manager

at INTEGRIS Health
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Posted 2 months ago

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About the role

  • Lead and coordinate a systemic approach for the hospital system’s regulatory compliance and accreditation programs, ensuring continuous readiness for surveys from accrediting bodies such as TJC, DNV, CMS, and State agencies
  • Act as a strategic partner to system and facility leadership and staff by providing expert guidance, resources, and support to facilitate compliance with regulatory and accreditation requirements
  • Foster a collaborative environment that encourages facilities to assume accountability for regulatory compliance and continuous quality improvement
  • Provide operational oversight and coordination of survey activities in collaboration with facility leadership, ensuring thorough preparation, efficient execution, and effective post-survey follow-up
  • Maintain and disseminate an accurate, comprehensive inventory of all applicable federal, state, and local regulatory and accreditation obligations across the hospital enterprise
  • Monitor compliance through audits, tracers, and data analysis; identify gaps and support corrective action planning and execution
  • Guide new departments, leaders, and facilities in meeting survey readiness and regulatory expectations
  • Serve as a representative/expert on committees and task forces related to regulatory compliance and safety events
  • Collaborate with policy governance stakeholders to support development, maintenance, and dissemination of policies aligned with regulatory and accreditation standards
  • Partner with clinical and operational leaders to advise on policy development, revision, implementation, and alignment with regulatory expectations
  • Support establishment of communication and dissemination plans and provide basic training and education on current regulatory standards, trends, and survey preparation
  • Establish tracking systems, compile data, and prepare reports on compliance metrics, survey outcomes, corrective action progress, and regulatory submissions
  • Manage accreditation-related portals, reference materials, and other regulatory tools and develop innovative solutions leveraging technology and data analytics
  • Work setting generally at the corporate office with occasional overnight travel outside of the OKC metro area; may include extra or atypical hours and frequent changes of work assignment and interruptions

Requirements

  • Five (5) years healthcare setting experience, acute care setting preferred
  • Strong working knowledge of TJC or DNV, CMS, and relevant state-specific regulatory requirements
  • Three (3) years professional development, consultation or leadership experience
  • Bachelor’s degree in nursing or a healthcare related field
  • Active and current clinical licensure
  • Proficient in EHR and other common computer applications (i.e., Microsoft Word, Teams, Excel, PowerPoint and others)
  • Must be able to communicate effectively in English (verbal/written)
  • Master’s Degree (preferred)
  • Certified Professional in Healthcare Quality (CPHQ) or similar (preferred; if not certified, will be required as part of a professional improvement plan)
  • Certification, knowledge, or expertise with performance improvement/CQI methodologies (e.g., Continuous Improvement, Lean Six Sigma) (preferred)
  • May require occasional overnight travel outside of the OKC metro area
  • May include working extra hours or atypical work hours
  • This position may have additional or varied physical demand and/or respiratory fit test requirements

Benefits

  • recently enhanced benefits package for all eligible caregivers
  • front loaded PTO
  • 100% INTEGRIS Health paid short term disability
  • increased retirement match
  • paid family leave

Job title

Hospital Regulatory and Accreditation Manager

Job type

Full Time

Experience level

Mid levelSenior

Salary

Not specified

Degree requirement

Bachelor's Degree

Location requirements

HybridOklahoma CityUnited States

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