luminishealth
Manager - Accreditation and Regulatory Affairs
At a Glance
- Location
- Annapolis, Maryland, United States
- Posted
- 2026-03-05T11:53:06-05:00
Key Requirements
Required Skills
Domain Knowledge
- Education
- Healthcare
- Regulatory
Benefits & Perks
edical, Dental, and Vision Insurance • Retirement Plan (with employer mat
Requirements
• Bachelor's degree in nursing, Healthcare Administration, Healthcare Information Management, or a related field, or equivalent combination of experience and education.
• Two (2) years of experience in management or leadership role within a large hospital or health system.
• Expert knowledge of the regulatory environment to include The Joint Commission, CMS, and the National Committee for Quality Assurance.
• Two years' experience with accreditation and regulatory standards and activities, including the survey process and follow up of corrective action plans.
• Proficiency in using Microsoft Office (Outlook, Teams, Excel, Word, and PowerPoint) and AMP.
• Strong analytic, project management, and problem-solving skills.
Responsibilities
1. Proactively leads the ongoing evaluation, planning and support of the LH continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission, CMS, Office of Healthcare Quality, as well as other regulatory accreditation, certifications, and applicable organizational licenses.
2. Supports workflow needs and develops strengths of content experts and other accreditation and regulatory leaders to support workflow accordingly. Serves as the system accreditation leader during any on-site survey.
3. Manages system and entity Accreditation and Regulatory Readiness Committees and provides oversight for the accreditation and regulatory specialists to review work plans and progress. Identifies growth and areas of opportunity to ensure Program initiatives are being met.
4. Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice.
5. Educates leaders, staff, medical staff and other stakeholders on the accreditation process and requirements.
6. Partners with regulatory content experts to identify risk areas and support development, implementation and monitoring of regulatory improvement processes.