Regulatory Compliance & Accreditation Program Manager Senior

It's more than a career, it's a calling.

OK-SSM Health St. Anthony Hospital Midwest

Worker Type:

Regular

Job Highlights:

Join a team where your work matters—every moment, every patient, every community. At SSM Health, you’ll be empowered to grow, supported to thrive, and inspired to make a lasting impact.

We’re seeking a Regulatory Compliance & Accreditation Program Manager Senior who combines strong regulatory knowledge with exceptional communication and organizational skills. This role is ideal for someone who enjoys connecting with people, is comfortable presenting to a variety of audiences, and can quickly review complex information and translate it into clear, actionable guidance. You’ll partner across teams to support regulatory compliance and accreditation readiness while helping leaders navigate requirements and maintain high standards. Clinical experience is preferred and can provide valuable perspective in connecting regulatory expectations to day-to-day healthcare operations.

Scheduling & Logistics:

The position is fully onsite in Midwest City, Oklahoma, with flexibility for one work-from-home day per week if needed (e.g., inclement weather).

Preferred candidates should reside in close proximity to Midwest City and Shawnee, Oklahoma. 

Standard work schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m.

Skills & Matching Criteria:

Enjoys speaking to people

Presentation experience

Ability to quickly review information

Well-organized

Clinical experience preferred

Apply today. SSM Health – We bring out the incredible in you, everyday!

Job Summary:

Provides strategic leadership for regulatory and accreditation activities across assigned ministries. Responsible for developing, implementing, and overseeing systems to ensure compliance with federal, state, and accreditation standards. Fosters a culture of compliance, drives alignment across multiple facilities, and proactively addresses regulatory risks.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Employs advanced communication skills to engage health care organization staff in interactive dialogues on a broad array of health care issues to assess compliance and to identify opportunities for improving compliance.

• Must possess sound understanding of High Reliability, Robust Process Improvement and Culture of Safety. Leads education and training. 

• Directs and manages all regulatory survey processes related to Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and Joint Commission standards. Serves as the subject matter expert during specialty external surveys.

• Oversees timely and effective responses to citations, including development and implementation of corrective action plans. Guides staff and processes to ensure compliance monitoring and enforcement. Coordinates governmental complaint investigations for hospitals, develops appropriate responses, and monitors compliance to reduce regulatory and accreditation risks.

• Engages in travel to other locations as needed.

• Performs regulatory surveillance and comprehensive mock surveys using CMS, Joint Commission, and state requirements. Leads and participates in internal assessments across ministries and regions. Leads and participates in a minimum of two Internal Comprehensive Assessments throughout the system, including in other regions and one virtual session or CMS Closed Record Review. This depends on the volume of ministries due for accreditation.

• Evaluates tracer data and compliance metrics to identify vulnerabilities. Recommends and implements improvements to ensure safe care delivery and regulatory readiness across ministries.

• Prepares and presents detailed compliance reports, updates, and annual summaries to senior leadership and Integrated Quality Council. Serves as a resource for departments to strengthen regulatory and legal compliance. 

• Collaborates on policy and process revisions in response to changing laws and regulations. Assesses internal controls for effectiveness and leads performance improvement initiatives to maintain accreditation standards.

• Performs other duties as assigned. 

EDUCATION

• Bachelor's degree or equivalent years of experience and education

EXPERIENCE

• Five years' experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.

• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.

• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.

• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.

• Frequent keyboard use/data entry.

• Occasional bending, stooping, kneeling, squatting, twisting and gripping.

• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.

• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 

• None

Department:

8754000033 Regulatory

Work Shift:

Day Shift (United States of America)

Scheduled Weekly Hours:

40

SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law. Read our notice of non-discrimination