Manager Hospital Regulatory and Accreditation

INTEGRIS Health Corporate Office, Oklahoma’s largest not-for-profit health system has a great opportunity for a Manager of Hospital Regulatory and Accreditation in Oklahoma City, OK. In this position, you’ll be a part of our Acute Quality and Quality Review team providing exceptional work supporting the INTEGRIS Health caregivers and the community at large. If our mission of partnering with people to live healthier lives speaks to you, apply today and learn more about our recently enhanced benefits package for all eligible caregivers such as, front loaded PTO, 100% INTEGRIS Health paid short term disability, increased retirement match, and paid family leave. We invite you to join us as we strive to be The Most Trusted Partner for Health. ​​

The Manager of Hospital Regulatory and Accreditation is responsible for assisting in maintaining a state of regulatory compliance across the INTEGRIS Health Hospital Enterprise by overseeing accreditation readiness activities, monitoring adherence to applicable standards, coordinating survey preparedness efforts, and supporting continuous improvement initiatives. This role servs as a subject matter expert on accreditation and regulatory standards to ensure that hospitals within the system meet or exceed requirements set forth by accrediting bodies and regulatory agencies, thereby promoting patient safety, quality of care, and organizational excellence. 

REQUIRED QUALIFICATIONS
EXPERIENCE:

• Five (5) years healthcare setting experience, acute care setting preferred
• Strong working knowledge of TJC or DNV, CMS, and relevant state-specific regulatory requirements
• Three (3) years professional development, consultation or leadership experience

EDUCATION:

• Bachelor’s degree in nursing or a healthcare related field

LICENSE/CERTIFICATIONS:

• Active and current clinical licensure

SKILLS:

• Proficient in EHR and other common computer applications (i.e., Microsoft Word, Teams, Excel, PowerPoint and others, as identified)

  Must be able to communicate effectively in English (verbal/written). 

PREFERRED QUALIFICATIONS

EDUCATION:

• Master’s Degree

LICENSE/CERTIFICATIONS:

• Certified Professional in Healthcare Quality (CPHQ) or similar.If not certified, will be required as part of a professional improvement plan
• Certification, knowledge, or expertise with performance improvement/CQI methodologies (e.g., Continuous Improvement, Lean Six Sigma).

The Manager of Hospital Regulatory and Accreditation responsibilities include, but are not limited to, the following:

Regulatory and Accreditation Oversight

• Lead and coordinate a systemic approach for the hospital system’s regulatory compliance and accreditation programs, ensuring continuous readiness for surveys from accrediting bodies such as TJC, DNV, CMS, and State agencies.
• Act as a strategic partner to system and facility leadership and staff by providing expert guidance, resources, and support to facilitate compliance with regulatory and accreditation requirements.
• Foster a collaborative environment that encourages facilities to assume accountability for regulatory compliance and continuous quality improvement.
• Provide operational oversight and coordination of survey activities in collaboration with facility leadership, ensuring thorough preparation, efficient execution, and effective post-survey follow-up.
• Maintain and disseminate an accurate, comprehensive inventory of all applicable federal, state, and local regulatory and accreditation obligations across the hospital enterprise.
• Monitor compliance through audits, tracers, and data analysis; identify gaps and support corrective action planning and execution.
• Guide new departments, leaders, and facilities in meeting survey readiness and regulatory expectations.
• Serve as a representative/expert on committees and task forces related to regulatory compliance and safety events.
• Works on other regulatory projects and duties as assigned.
• Policy Governance and Standardization
• Collaborate with the Manager of System Policy Governance, Policy Owners, Policy Area Managers, and other stakeholders and teams to support the development and maintenance of policies that are current, compliant, and aligned with applicable regulatory and accreditation standards.
• Partner with clinical and operational leaders to advise on the development, creation, revision, implementation, and alignment of policies that impact regulatory readiness and clinical practice.
• Support the establishment of effective communication and dissemination plans to ensure timely awareness of policy updates across all relevant stakeholders, to ensure they understand their roles and responsibilities through training sessions and accessible resources.
• Assist in monitoring key aspects of clinical policy lifecycle management, including review timelines, formatting consistency, and documentation of approvals, in coordination with policy owners to ensure policies are thoroughly evaluated and meet regulatory and accreditation standards before they are implemented.
• Regularly assess performance and effectiveness policies to identify gaps in compliance with regulatory and accreditation policies and procedures.
  Continuous Improvement and Organizational Culture
• Champion a culture of continuous regulatory readiness and quality improvement by encouraging innovation, collaboration, and best practice sharing among facilities.
• Facilitate system-wide communication and dissemination of corrective actions and lessons learned to drive organizational learning and enhanced compliance outcomes.
• Promote cross-facility collaboration to leverage collective expertise and resources in advancing quality, safety, and patient experience objectives.
  Education, Communication, and Reporting
• Provides basic training and education to leaders, staff, and physicians on current regulatory standards, trends, and survey preparation.
• Establish tracking systems to routinely assess and communicate the status of compliance initiatives and survey readiness.
• Compile data and prepare reports on compliance metrics, survey outcomes, corrective action progress, and regulatory submissions.
• Ensure timely submission of all required regulatory reports to external agencies.
  Technology, Tools, and Resources.
• Manage accreditation-related portals, reference materials, and other regulatory tools used across the health system.
• Maintain system-wide access to current regulatory guidance, policies, and best practices.
• Develop and implement innovative solutions to enhance the management of survey activities, including leveraging technology, data analytics, and process improvements to increase efficiency, accuracy, and readiness across the hospital enterprise.
• The work setting will generally be at the corporate office; however, the position does require occasional overnight travel outside of the OKC metro area.May also include working extra hours or atypical work hours.
• This position may have additional or varied physical demand and/or respiratory fit test requirements. 
• Frequent changes of work assignment and interruptions.