System Manager of Regulatory & Accreditation

Join TriHealth as a System Manager of Regulatory & Accreditation!

Are you a strategic leader with expertise in healthcare accreditation and regulatory compliance? At TriHealth, you'll drive continuous readiness, mentor operational leadership, and ensure TJC, CMS, and ODH compliance while fostering a high-reliability culture. If you're passionate about healthcare excellence and collaborative leadership, we’d love to hear from you!

Job Overview:

We are seeking a highly knowledgeable System Manager of Regulatory & Accreditation to ensure compliance with Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and Ohio Department of Health (ODH) requirements. This role requires a broad and detailed understanding of hospital structure and operations and involves extensive collaboration with staff, managers, directors, vice presidents, and site leadership.

The ideal candidate will serve as a strategic advisor, mentor, and coach to operational leadership, helping teams maintain accreditation standards and regulatory readiness while fostering a culture of continuous improvement. Success in this role requires diplomacy, tact, and a collaborative approach to problem-solving and leadership.

Job Requirements:

• Master’s Degree in a related field (Required)
• 3-4 years of professional experience with TJC and other regulatory bodies (Required)
• 4-5 years of professional healthcare clinical experience (Required)
• Strong understanding of hospital operations (Preferred)
• Nursing or allied healthcare experience with certification (Preferred)

Key Responsibilities: Continuous Readiness & Compliance Leadership

• Drive a culture of continual accreditation readiness, ensuring compliance with TJC and other regulatory standards.
• Provide guidance, mentorship, and training to operational leadership on best practices for regulatory compliance.
• Develop policies and procedures that align with industry standards while supporting efficient hospital operations.

Department Leadership & Team Engagement

• Lead daily operations for the regulatory & accreditation department, ensuring engagement and retention of staff.
• Develop and manage budgets, advising hospital presidents on accreditation-related financial planning.
• Recruit, hire, coach, and evaluate direct reports, fostering a productive and positive work environment.

Survey & Complaint Management

• Serve as the organizational leader during planned and unplanned accreditation surveys and complaint visits.
• Implement structured and proactive survey readiness programs across the organization.
• Oversee responses to regulatory complaints, ensuring timely resolution and compliance with expectations.

Regulatory & Accreditation Strategy

• Stay ahead of emerging regulatory trends and focus areas, providing expert insights to hospital leadership.
• Engage with internal teams to address accreditation challenges, ensuring a collaborative and effective resolution process.
• Deploy a proactive survey readiness program, establishing high-reliability practices across the system.

Additional Information:

This role requires an individual with deep expertise in hospital accreditation, regulatory compliance, and healthcare operations. Extensive interaction with staff, leadership teams, and site executives will be expected. The ability to communicate complex regulatory requirements in a clear, engaging, and collaborative manner is essential. Travel required to various sites for surveys and compliance meetings

Working Conditions:
This role requires a dynamic and engaged professional with a balance of strategic thinking and hands-on involvement across various healthcare settings. Candidates should be prepared for the following workplace conditions:

Physical Activity:

• Bending, climbing, kneeling, and stooping – Rarely
• Lifting (50+ lbs.), pulling, pushing, and reaching – Occasionally
• Sitting, standing, walking – Frequently

Cognitive & Sensory Demands:

• Concentrating, thinking/reasoning – Consistently
• Continuous learning – Consistently
• Reading, talking, interpersonal communication – Frequently
• Hearing (conversation and other sounds) – Frequently

Motor & Visual Requirements:

• Use of hands – Frequently
• Color vision, near/far visual acuity – Frequently

Leadership Performance Standards

TriHealth leaders create a culture of engagement, safety & reliability and high performance by consistently modeling and utilizing the following TriHealth Way leadership competencies, tactics and ALWAYS Behaviors to drive strategic pillar results:

Achievement of Annual Pillar Goals:
1) Safety/Quality, 2) Service, 3) Growth, 4) Culture/People, 5) Finance

Leadership Competencies:
TriHealth Way of Leading
TriHealth Way of Serving
Transformation Change
Drive for Results
Build Organizational Talent

Leadership Tactics:
Conduct department huddles. Generally, clinical departments hold daily huddles, non-clinical hold weekly huddles.
Regularly Round on Team Members, using questions from the rounding log.
- 25 or fewer team members = monthly
- 26-50 team members = every other month
- 51+ (and optional team members) = quarterly

Lead monthly team meetings using meeting agenda template; review stoplight report; cascade key leadership messages.

Model, coach and validate team members use of TriHealth Way behaviors (AIDET + Promise, Always Behaviors and Always HEARD).

Recognize team members for safety wins, positive performance and demonstrating SERVE and ALWAYS behaviors, TriHealth Way of Leading, Serving and Delivering Care.