Regulatory Compliance Program Manager

Patient Safety And Accreditation Program Coordinator

Provides operational support and overall coordination for the strategic implementation of patient safety and accreditation programs. Ensures all facets of patient safety are identified, and coordinated into a comprehensive plan. Ensures assigned hospitals and clinics are aligned with Joint Commission and standards established through state and federal regulations. Facilitates on-going regulatory compliance activities through extensive rounding on clinical and non-clinical departments at CHI-FH. Work includes; policy and procedure implementation; survey preparation; survey management and follow-up; assessment of standards compliance and reporting of vulnerabilities to key stakeholders; conducting training in response to identified or potential deficiencies to management, educators and staff. Assists in review / trending of incident report information and provides quality information for internal quarterly review and ongoing physician performance evaluation. Provides guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs as well as ensuring ongoing compliance with state and federal rules and regulations. Incumbent is accountable for keeping knowledge and skills current in assigned subject area through self-education, community networking and professional organization offerings.

Job Requirements :

• Bachelor's degree in healthcare administration, nursing or other healthcare-related field.
• Five years of progressively responsible related work experience that would demonstrate attainment of the requisite job knowledge.
• Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization's or department Quality, Safety, or Regulatory Program.
• Minimum of two (2) years of clinical, patient experience or equivalent.
• Experience developing, and implementing clinical, service and operation process initiatives, both small and large scale.
• Any equivalent combination of education and experience which meets requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.
• Preferred : Active Washington State Registered Nurse License
• Certified Professional in Healthcare Quality (CPHQ)

Where You'll Work :

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area. Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person body, mind, and spirit in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth. Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care. We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.