Registered Nurse (RN) Program Manager Accreditation and Regulatory

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

 

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:

  • Provide support 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 coordinate entity-specific unannounced survey plans.

  • Co-manage on-site surveys and logistics.

  • 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 Administrat