Manager, Accreditation & Regulatory Compliance

About the role

Oversee regulatory readiness activities across clinical and operational departments, ensuring compliance with CMS, The Joint Commission, and state regulations.

Responsibilities

• Manage internal audits, mock surveys, tracer programs, and staff training
• Lead accreditation, licensing, and regulatory compliance efforts
• Coordinate surveys and implement improvement processes to maintain continuous readiness
• Collaborate with clinical, medical, and administrative teams to embed regulatory standards into daily operations, policies, and performance initiatives
• Strategic partnership with leadership to develop and monitor compliance programs
• Conduct annual assessments, manage regulatory documentation, and respond to adverse events and citations

Qualifications

• Bachelor’s degree; master’s preferred
• Minimum of 5 years healthcare or related experience
• 3 years in compliance or process improvement
• 2 years leadership experience
• Required certifications: Healthcare Accreditation Certificated Professional (HACP) or CPHQ, to be obtained within 2 years

Skills

• Strong organizational, analytical, and communication skills
• Ability to ensure ongoing compliance and risk mitigation