Program Manager. Accreditation and Regulatory

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Occ Summary

The Accreditation and Regulatory Program Manager plays a key collaborative role in supporting accreditation, regulatory, and disease-specific certification efforts across Duke University Hospital and Duke Raleigh Hospital, A Campus of Duke University Hospital. This position works closely with leadership, staff, and medical teams to ensure shared understanding and alignment with standards, contributing to a culture of excellence in patient care.

The Program Manager partners with stakeholders to maintain a continuous readiness infrastructure, applying regulatory knowledge and improvement methodologies to support teams in achieving and sustaining compliance. This role serves as a resource, educator, and facilitator-helping departments assess, measure, and report compliance, promote best practices, and coordinate survey processes. In collaboration with operational, executive, and medical leadership, this role contributes to the goals of the DUHS Accreditation and Regulatory Program:

• Standard Interpretation
• Standard Compliance
• Education and Communication
• Survey Operations

This position supports accreditation and regulatory activities through shared ownership and teamwork, contributing to the strategic execution of related initiatives.

Work Performed

Support Continuous Readiness Efforts:

• Collaborate with departments to maintain proactive compliance and readiness for accreditation and certification.
• Partner with Patient Safety, Quality, Risk, Legal, and other teams to assess and support regulatory compliance.
• Assist in identifying and mitigating regulatory risks in coordination with leadership.
• Contribute to accreditation and regulatory initiatives and help monitor corrective actions.
• Provide support in interpreting standards and requirements.
• Participate in internal assessments (e.g., tracers, mock surveys).
• Help analyze survey trends and support implementation of risk reduction strategies.
• Assist in updating policies and developing educational tools based on findings.

Resource Development and Management:

• Help create and maintain toolkits, presentations, and reference materials.
• Support the upkeep of regulatory resources (e.g., AMP, CMS guidelines).
• Facilitate education sessions and assist with policy alignment to standards.

Collaborative Support and Expertise:

• Serve as a supportive resource for accreditation and regulatory bodies.
• Monitor regulatory updates and share relevant information with teams.
• Contribute to continuous improvement efforts
• Work with leadership to support policy and process improvements.

Survey Coordination:

• Assist in developing and coordinating unannounced survey plans.
• Support logistics and real-time coordination during on-site surveys.
• Help manage communication and agendas during survey activities.

Corrective Action Plans and Application Oversight:

• Collaborate on the development of corrective actions in response to findings.
• Help monitor progress and support sustainability of improvements.
• Ensure timely submission of required documentation.
• Participate in follow-up internal surveys and reporting.

Knowledge, Skills and Abilities

• Familiarity with CMS Conditions of Participation and accrediting body standards (e.g., TJC, AAAHC).
• Understanding of quality improvement, project management, and healthcare operations.
• Strong analytical, facilitation, coaching, and communication skills.
• Ability to collaborate effectively across teams and departments.
• Experience with auditing, training, and risk assessment.
• Self-motivated, team-oriented, and capable of exercising sound judgment.
• Ability to build trust and foster multidisciplinary cooperation.

Minimum Qualifications

Education
Bachelor's degree in Nursing, Business, or Healthcare Administration required.
Master's degree preferred.

Experience
5 years of experience in accreditation, certification, quality, risk management, patient safety, or clinical operations.
2 years of healthcare/patient care experience preferred. RN experience preferred.
Knowledge of regulatory standards (NCQA, TJC, AAAHC, CMS).
On-site presence required for unannounced survey readiness.

Degrees, Licensures, Certifications
RN strongly preferred or other licensed clinical professional preferred.

Duke is an Equal Opportunity Employer
Committed to providing employment opportunities regardless of age, color, disability, gender identity or expression, genetic information, national origin, race, religion, sex (including pregnancy), sexual orientation, or military status.

Physical Job Functions:
Some positions at Duke University and Duke University Health System may require specific physical or mental abilities. Reasonable accommodation requests will be handled by each hiring department.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends onthe robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.