Duke University

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Occ Summary

The Accreditation and Regulatory Program Manager is responsible for collaborating, at a system/entity level at Duke University Hospital and Duke Raleigh Hospital, A Campus of Duke University Hospital, with leadership, staff, and medical staff to provide a proactive, global, and unified perspective on accreditation, regulatory, and disease-specific certification requirements and activities. This position plays a pivotal role in leading efforts to achieve the highest compliance with accreditation and certification standards, ensuring practices not only meet but exceed benchmarks for patient care excellence.

This role supports a continuous readiness infrastructure by leveraging deep regulatory knowledge and improvement methodologies. The manager acts as a resource, mentor, and educator for regulatory and accreditation programs, working across the organization to assess, measure, and report compliance; promote best practices; and standardize survey processes. In collaboration with operational, executive, and medical leadership, this role ensures alignment with the DUHS Accreditation and Regulatory Program goals:

1. Standard Interpretation
2. Standard Compliance
3. Education and Communication
4. Survey Operations

This position includes programmatic ownership of accreditation and regulatory activities and the strategic execution of related initiatives.

Work Performed

• Lead Continuous Readiness Efforts:
  • Drive proactive compliance and readiness infrastructure for accreditation and certification.
  • Collaborate with departments such as Patient Safety, Quality, Risk, Legal, and more to assess compliance.
  • Identify and mitigate regulatory risks in partnership with leadership.
  • Lead accreditation and regulatory compliance initiatives and track corrective actions.
  • Guide interpretation of standards and requirements.
  • Support and conduct internal assessments (e.g., tracers, mock surveys).
  • Analyze and report survey trends; implement risk reduction activities.
  • Update policies and develop education tools based on findings.
• Resource Development and Management:
  • Create toolkits, presentations, and reference materials.
  • Maintain regulatory resources (e.g., AMP, CMS guidelines).
  • Conduct education sessions and support policy alignment with standards.
• Leadership and Expert Resource:
  • Act as primary contact for accreditation/regulatory bodies.
  • Monitor updates in regulations and disseminate relevant information.
  • Support continuous improvement through LEAN, PDCA, DMAIC methodologies.
  • Partner with leadership on implementing policy improvements.
• Survey Coordination:
  • Develop and manage entity-specific unannounced survey plans.
  • Co-manage on-site surveys and logistics.
  • Serve as point-of-contact for surveyors.
  • Support communication, agendas, and real-time coordination.
• Corrective Action Plans and Application Oversight:
  • Guide development of corrective actions in response to findings.
  • Monitor progress and sustain improvements.
  • Ensure timely submission of required documentation.
  • Conduct follow-up internal surveys and report on implementation outcomes.

Knowledge, Skills and Abilities

• Knowledge of CMS Conditions of Participation and accrediting body standards (e.g., TJC, DNV).
• Understanding of quality improvement, project management, and healthcare operations.
• Strong analytical, facilitation, coaching, and communication skills.
• Ability to influence across teams without direct authority.
• Experience with auditing, training, and risk assessment.
• Self-motivated, collaborative, and capable of independent 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.
• Must have knowledge of regulatory standards including CMS, TJC, DNV, TJC, JACO, DHHS, DHSR, DOH.
• On-site presence required for unannounced survey readiness.
• Preferred: Clinical operations experience, data analytics, training, accreditation readiness, and project leadership.

Degrees, Licensures, Certifications

• RN or other licensed clinical professional preferred.
• Preferred certifications include:
  • CPHQ – Certified Professional in Healthcare Quality
  • ASQ Certified Quality Technician
  • HACP – Healthcare Accreditation Certified Professional
  • CSHA – Certified Specialist in Healthcare Accreditation

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.