Program Manager - Accreditation and Regulatory Compliance

HealthPartners • Saint Louis Park, MN

1d

About The Position

This role is responsible for leading, coordinating, and advancing all regulatory and accreditation activities across Park Nicollet Methodist Hospital (PNMH) and its affiliated entities, including the Methodist Hospital, Melrose Institute, and Methodist Hospital homecare, hospice, home infusion, and DME programs. The role encompasses oversight of compliance with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, The Joint Commission (TJC) standards, and hospital-based specialty accreditations. This position supports continuous readiness through proactive regulatory risk reduction strategies, educational initiatives, and policy development to ensure adherence to evolving standards. The scope of this role includes serving as the principal subject matter expert (SME) for TJC program manuals and other regulatory frameworks, providing leadership in policy alignment, staff education, and process improvement. The Program Manager partners with organizational leadership and multidisciplinary teams to drive high reliability and foster a culture of patient safety and operational excellence. Additionally, the role facilitates survey readiness and directs all activities associated with regulatory survey visits to achieve successful outcomes.

Requirements

• Bachelor’s Degree in Nursing, Quality Management, Hospital Administration or healthcare related field.
• 2+ years of experience leading or supporting TJC accreditation processes, regulatory surveys, or other healthcare compliance programs.
• Expert knowledge of The Joint Commissions (TJC), Centers for Medicare and Medicaid Services (CMS), Minnesota Department of Health (MDH)and other related standards and regulations
• Familiarity with OSHA, Building and Fire codes
• PDSA (Plan, Do, Study, Act) experience
• Leadership of on-site surveys
• Manage the surveillance function for reporting and regulatory and compliance changes
• Proficient in interpretation and application of standards with proven success in performing gap assessment and assignment of criticality/risk.
• Ability to identify and collaborate with key stakeholders to develop clear action plans and oversee their implementation
• Monitor and validate ongoing compliance readiness of the organization
• Successfully demonstrated ability to lead large scale projects and utilize performance improvement methods such as Lean or Six Sigma
• Ability to effectively communicate with individuals from all disciplines and all levels of the organization
• Excellent critical thinking skills
• Exceptional capabilities in leading, collaborating and influencing teams and individuals to improve performance and compliance
• Excellent verbal and written communication skills including the ability to communicate complex information in a clear, concise and professional manner.
• Demonstrated ability to prepare and present to senior leadership
• Highly skilled in analyzing data and presenting data to identify opportunities and drive decisions
• Ability to successfully and independently use technology including ability to create templates, tables and tracking tools, PowerPoint presentations.

Nice To Haves

• Master’s degree in healthcare or business
• Five (5) years of experience in accreditation and/or regulatory compliance
• Compliance work experience in a healthcare setting and demonstrated experience regularly interacting with other healthcare regulatory agencies.
• Green belt or black belt certification
• Lean or Six Sigma training and/or certification
• CPHQ (Certified Professional in Healthcare Quality
• ASQ (American Society for Quality) certification
• Certified Joint Commission Professional (CJCP)
• Coursework in statistical analysis
• Experience with electronic medical record

Responsibilities

• leading, coordinating, and advancing all regulatory and accreditation activities across Park Nicollet Methodist Hospital (PNMH) and its affiliated entities
• oversight of compliance with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, The Joint Commission (TJC) standards, and hospital-based specialty accreditations
• supports continuous readiness through proactive regulatory risk reduction strategies, educational initiatives, and policy development to ensure adherence to evolving standards
• serving as the principal subject matter expert (SME) for TJC program manuals and other regulatory frameworks
• providing leadership in policy alignment, staff education, and process improvement
• partners with organizational leadership and multidisciplinary teams to drive high reliability and foster a culture of patient safety and operational excellence
• facilitates survey readiness and directs all activities associated with regulatory survey visits to achieve successful outcomes

Benefits

• Park Nicollet offers a competitive benefits package (for eligible positions) that includes medical insurance, dental insurance, a retirement program, time away from work, insurance options, tuition reimbursement, an employee assistance program, onsite clinic and much more!
• As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level