Accreditation & Regulatory Compliance Manager - Community and Rural Health

Days - Full Time

Liberty Hospital

Position Summary / Career Interest:

The Community and Rural Health Accreditation and Regulatory Compliance Manager provides system‑wide leadership for accreditation and regulatory compliance and readiness across the health system's community hospitals and Rural Health Clinics. This role ensures consistent interpretation and application of Joint Commission, CMS, state, and Rural Health Clinic requirements by planning, coordinating, and implementing efforts to maintain accreditations and certification. The manager oversees the development of standardized processes, guides leaders through compliance expectations, and oversees the monitoring if organizational compliance. The manager oversees a distributed team of site‑based compliance professionals who partner with hospital and clinic leaders, frontline staff, and disease‑specific program owners to assess compliance, identify gaps, and drive sustainable improvements. This position plays a key role in maintaining continuous survey readiness, supporting system integration efforts, and strengthening a culture of safety, accountability, and regulatory excellence across all locations.

Responsibilities and Essential Job Functions

• Coordinates accreditation and regulatory activities for the Health System’s Community hospitals and affiliated care locations to ensure all entities are in compliance with required standards and maintains an integrated, consistent plan for continuously complying with all required TJC standards, CMS Conditions of Participation (CoPs) and Kansas and Missouri regulations, as applicable.
• Coordinates compliance efforts for Rural Health Clinics throughout the health system.
• Manages the accreditation staff and oversees the daily functions of the Accreditation & Regulatory Compliance Department at community hospital sites and affiliated locations throughout the metropolitan area.
• Designs and implements a systematic approach to ensure a high level of awareness of accreditation and regulatory agency requirements throughout the hospitals.
• Implements an ongoing organizational needs assessment for regulatory compliance and makes recommendations based on the assessment.
• Identifies educational issues related to accreditation and regulatory compliance and designs and implements staff education plans to meet those opportunities. Assists in education of the Medical Staff related to regulatory compliance.
• Leads continuous readiness efforts and coach others in the development of accreditation improvement capabilities. Provides direction to department and facility leadership in planning of a systematic, organization-wide approach to continuous regulatory readiness.
• Coordinates regulatory compliance and accreditation activities as assigned.
• Coordinates compliance with the CoPs.  Stays abreast of current developments/changes in CoP requirements.  Develops and recommends necessary plans of action to the appropriate department(s) and follows implementation to completion.
• Participates in the development and implementation of policies and guidelines as they relate to the hospital and compliance with regulatory guidelines and assist in the interpretation of these policies.
• Manages and provides oversight of accreditation and regulatory compliance activities to ensure ongoing readiness for unannounced surveys by TJC, and Federal, State, and local regulations.
• Cultivates and manages organizational relationships with accreditation organizations.
• Directs preparation of written responses and development of corrective action plans regarding The Joint Commission, CMS and other regulatory recommendations.
• Serves as a coordination point and resource for hospital accreditation, certification, and licensure requirements as set forth by Federal, State, and local regulations.
• Responsible for all aspects of the management of the department including, but not limited to:Interviewing, selecting, orienting, evaluating, and terminating staff.
• Planning for the professional development of staff.
• Assisting in development and completion of annual department goals.
• Ensuring staff (and self) complete annual employee health requirements and annual mandatory education.
• Demonstrates good organizational skills in the preparation of daily work schedules and the assignment of duties and responsibilities to staff members.
• Involve accreditation and regulatory team members in decision making.
• Maintains competency in accreditation and regulatory requirements, and enhances professional growth and development through continuing education, conferences and seminars.
• Travel to off-site health system locations required, including but not limited to Liberty, Olathe, Paola, Kansas City, and Great Bend.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Master's Degree OR
• 5 or more years hospital accreditation and regulatory compliance position
• 5 or more years healthcare experience

Preferred Education and Experience

• Previous leadership or project management experience

Required Licensure and Certification

• CJCP or HACP upon Hire

Knowledge Requirements

• Proven ability to interact effectively with employees and outside parties of all levels and cultures required.
• Excellent customer services skills.
• Experience working directly with clients on day-to-day activities.
• Ability to manage multiple projects.
• Excellent written and verbal communication skills.
• Ability to use Microsoft Office (Access, Excel, PowerPoint, and Outlook).
• Fast-paced environment requiring adaptability and strong problem-solving skills.
• Strong leadership and coaching skills
• Excellent communication, facilitation, and interpersonal skills to engage stakeholders at all levels.

Time Type:

Full time

Job Requisition ID:

R-57281

Important information for you to know as you apply:

• The health system is an equal employment opportunity employer.  Qualified applicants are considered for employment without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, ancestry, age, disability, veteran status, genetic information, or any other legally-protected status.  See also Diversity, Equity & Inclusion.

• The health system provides reasonable accommodations to qualified individuals with disabilities.  If you need to request reasonable accommodations for your disability as you navigate the recruitment process, please let our recruiters know by requesting an Accommodation Request form using this link [email protected].

• Employment with the health system is contingent upon, among other things, agreeing to the health-system-dispute-resolution-program.pdf and signing the agreement to the DRP.

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