Manager-Regulatory Affairs

Position Description:
STATEMENT OF VALUES:
Cooper Green Mercy strives to be THE choice for health care in our community. We honor this commitment by embracing our core values of:

• Kindness,
• Inclusion,
• Cleanliness, and;
• Attention to Detail.

GENERAL SUMMARY
Dedicated and knowledgeable, the Regulatory Program Manager ensures that Cooper Green remains in full compliance with all applicable Centers for Medicare & Medicaid Services (CMS) regulations and maintains its accreditation status, if pursued, with relevant healthcare accrediting organizations (e.g., The Joint Commission, NCQA). This role will track and drive adherence to Health Resources and Services Administration (HRSA) requirements. The Regulatory Program Manager has a strong understanding of healthcare laws, regulatory requirements, HRSA Federally Qualified Health Center requirements, CMS policies, and accreditation standards. This role will be responsible for maintaining a gap analysis; monitoring, auditing, and implementing strategies to ensure the facility meets requirements and upholds the highest standards for our patients; organizing groups; managing projects; assisting with policies and procedures; and educating staff.

KEY RESPONSIBILITIES

• Ensure the healthcare facility meets or exceeds all CMS regulations, guidelines, and standards.
• Manages the facility’s overall accreditation and CMS strategy.
• Develop, implement, and maintain internal programs to meet CMS requirements and regulatory expectations.
• Assist in the development, implementation, and maintenance of programs, agreements, and relationships to meet CMS requirements and regulatory expectations.
• Lead the facility's efforts in pursuing accreditation status with organizations such as The Joint Commission, NCQA, or others, including preparing for and supporting accreditation surveys and audits.
• Conduct regular audits and assessments of facility processes, records, and documentation to identify potential gaps in CMS, HRSA, and accreditation adherence.
• Create and/or provide ongoing education and training to staff on pertinent regulations, accreditation standards, and best practices.
• Collaborate with various departments, including clinical, operational, and administrative teams, to support and promote a culture of constant regulatory and accreditation adherence.
• Monitor regulatory and accreditation changes, ensure policies, procedures, and protocols are updated accordingly to meet requirements.
• Develop and maintain comprehensive documentation of CMS and HRSA compliance and accreditation activities, audit results, and corrective actions.
• Prepare and submit reports to executive leadership team regarding status, accreditation readiness, findings, and recommendations for improvement.
• Act as a liaison between the facility, CMS, accrediting organizations, and regulatory bodies, responding to inquiries, audits, or investigations as needed.
• Support the development of corrective action plans (CAPs) proactively to correct known deficiencies, in response to findings and assist with the implementation of corrective actions.
• Ensure that all required CMS certifications, accreditation reporting, HRSA reporting, and documentation deadlines are met.
• Assist in preparing for routine or surprise CMS, HRSA, and accreditation reviews and ensure continuous readiness for surveys and audits.
• Serve as consultant to supervisors and managers pursuing quality improvement projects.
• Stay abreast of best practices in the field of readiness and bring to the facility the practices that best fit our culture and model.
• Other duties as assigned.

Position Requirements:
MINIMUM QUALIFICATIONS
Required Education:

• Bachelor’s degree in Healthcare Administration, Public Health, or a related field

Required Experience:

• At least 3 years of experience in healthcare accreditation, quality and patient safety, project management, and/or healthcare physical environment, with a focus on CMS regulations and accreditation processes. Combination of experience and graduate education, in related field, can be used to satisfy requirement.

Preferred Qualifications:

• Master’s degree in Healthcare Administration, Public Health, or a related field.
• Certification in Healthcare Accreditation (HACP-CMS) or similar professional certification is preferred.

WORK ENVIRONMENT

• Full-time position with standard business hours.
• Occasional travel may be required for training sessions and locally for site visits.
• Flexible work environment with partial-remote work opportunities.