Program Manager, Regulatory Surveillance & Compliance Job

Saint Paul, MN, 55101
Dec 14, 2012
Feb 28, 2013
Management, Security
Employment Status
Full Time
Program Manager, Regulatory Surveillance & Compliance

Job ID: 25670
Department: Quality Performance Improvement
City: St. Paul, MN
Location: RH - Regions Hospital & Clinics
Position Type: Full-Time
Anticipated Work Schedule: Monday - Friday
Shift: Day
Hrs/Pay Period: 80

Job Description:

This position reports to the Director of Patient Safety, Accreditation and Compliance. The program manager will lead by establishing a systematic approach in setting priorities, identifying risk, providing education, mentoring and evaluating the organizational regulatory and accreditation readiness. Coordinates accreditation activities and programs including the survey readiness programs. Accountable for managing and accessing accreditation and compliance changes and risk from internal and external sources. Creates the interpretation of standards, perform gap assessment, assignment of criticality/risk. Identify and collaborate with key stakeholders to develop action plans with oversight of implementation. Accountable for monitoring and tracking ongoing compliance readiness of the organization. Continual Readiness Rounds, Tracer process system wide. Develops and maintains a surveillance program to monitor for new regulations, and best practices. Identifies and leads process improvement initiatives related to accreditation and compliance procedures and continuous readiness. Coordinates focused audits and serves as an expert resource on accreditation and compliance issues. Develops and implements strategies to ensure compliance with accrediting agencies. Provides communication and develops education to the organization regarding accrediting and internal standards, policies and procedures.

The individual must be a team player with superb communication and presentation skills. This position requires a hands-on leader who is an expert in regulations and accreditation standards. The program manager must have demonstrated abilities to coordinate, lead and manage on-site surveys with success. This must include developing responses to regulatory agencies following surveys or a focused request. The program manager must have a proven record of developing goals and achieving success through, development of relationships and process skills to ensure that partnerships, improvement and compliance is maintained across the hospital system. The program manager is expected to have an appropriate sense of urgency to react to situations quickly and decisively.


Bachelor's of Science degree in quality management, nursing, hospital administration or healthcare-related field. Master's degree in business or health care preferred.

Five years direct experience successfully leading organization-wide accreditation and regulatory compliance programs to include leadership of on-site surveys. Five years experience in project management. Five years experience in leading enterprise-wide initiatives and programs.

And two of the following required:
PMP (Project Management Professional) certification or
Green Belt or Black Belt certification or
Lean or Six Sigma training and certification

Or one of the above plus one of the following:
CPHQ (Certified Professional in Healthcare Quality) or ASQ (American Society for Quality) certification
PDSA (Plan, Do, Study, Act) experience

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