Program Manager, Regulatory and Accreditation

About the role

The Program Manager, Regulatory/Accreditation position at Endeavor Health is responsible for coordinating and serving as the primary contact for system-wide complex accreditation, certification, and regulatory activities. This includes reviewing abuse allegations, preparing surveys, and conducting readiness assessments for facilities within the organization.

Responsibilities

• Lead preparation for regulatory activities at assigned entities, departments, business lines, and institutes.
• Collaborate with content area experts to ensure continuous readiness throughout the organization.
• Develop compliance strategies and tactics for senior and executive leaders.
• Maintain and monitor regulatory reporting for assigned entities.
• Support the Joint Commission and Illinois Department of Public Health (IDPH) related to Evidence of Standards Completion (ESC) or other post-survey activities.
• Assist in system-wide accreditation and regulatory activities, including survey preparation and readiness assessments.
• Interpret standards and regulations and serve as a secondary point of contact for accreditation bodies.
• Provide education for organizational leaders on regulatory and accreditation issues.
• Identify learning needs and opportunities, researching training content and methods in collaboration with key areas impacted.
• Maintain awareness of regulatory websites for new information and changes, evaluating compliance towards those changes.
• Lead readiness efforts at assigned entities, departments, and institutes.

• Requirements

  • Bachelor’s degree required.
  • 5+ years of experience in a clinical setting.
  • 3+ years of experience in quality, risk management, or regulatory/accreditation roles.
  • Familiarity with TJC, CoP, IDPH, EPIC, and hospital clinical and operational workflows.
  • Commitment to staying current with evolving regulations, standards, and best practices in healthcare.
  • Excellent written and presentation skills.
  • Experience managing accreditation/change projects, including timeliness, resource allocation, and team coordination.
  • Data analysis proficiency in MS Excel.
  • Effective writing skills for policies, procedures, and compliance reports.
  • Ability to collect, analyze, and report data to demonstrate compliance.
  • Ability to navigate complex regulatory and legal issues related to healthcare delivery.
  • Ability to effectively communicate regulatory requirements and changes to all levels of staff and leadership.
  • BLS (Basic Life Support) – American Heart Association (AHA) required.

  Preferred Qualifications

  • Registered Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR) preferred or certified.
  • Certified Professional in Patient Safety (CPPS) – Certification Board for Professionals in Patient Safety (CBPPS) CHRM, CPPS, or CQP preferred.

  Benefits

  • Premium pay for eligible employees.
  • Career pathways to promote professional growth and development.
  • Variety of medical, dental, and vision options.
  • Tuition reimbursement.
  • Free parking at designated locations.
  • Wellness program savings plan.
  • Health savings account options.
  • Retail options with company match.
  • Paid time off.
  • Community involvement opportunities.