Published: December 13, 2016
Job Type
To $80K
Healthcare Services
Job ID


Our client, a leading national healthcare services company, is seeking an Accreditation and Regulatory Manager. In this role, you will support the regulatory, accreditation and contractual compliance of the hospital with a focus on Joint Commission Survey readiness.

Primary Responsibilities of an Accreditation and Regulatory Manager – Joint Commission:

  • Technical support for regulatory, accreditation and contractual (payer) compliance, including coordination of Joint Commission Survey readiness (application, pre and post survey follow up), reporting of various regulated and organization metrics
  • Compile high level Joint Commission readiness reports on a monthly basis for the purpose of senior level reporting.
  • Review policy and procedures to assure regulatory compliance.
  • Coordinate accreditation committee, including assignment of Joint Commission readiness for each team.
  • Provide education to responsible clinical / non-clinical and administrative staff regarding the requirements of the applicable regulations and standards.
  • Facilitate and lead teams to fulfill compliance and required metrics as needed. Liaise to the Medical Staff Department, Medical Records Department, and other various departments to assure ongoing regulatory compliance.
  • Assist all clinical and non-clinical departments to assure Scope of Service compliance, evaluations and privileging.
  • Perform clinical pertinence review function and prepare summary reports for review by Chiefs and Medical Executive Committee.

A successful Accreditation and Regulatory Manager will have:

  • Bachelor’s Degree, nursing and clinical experience preferred.
  • At least 3 years’ experience with accreditation and licensing survey preparation and implementation in a healthcare setting, as guided by Joint Commission, CMS, payer requirements and metrics.
  • Knowledge of organizational learning methods.
  • Knowledge of group facilitation techniques.
  • Strong interpersonal skills.
  • Strong written and oral communication skills.
  • Microsoft Office skills including Excel and Access.

Keywords: healthcare compliance, healthcare regulations, regulatory, The Joint Commission, mental health, CMS, Centers for Medicare and Medicaid Services, Massachusetts healthcare, payer requirements

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