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Job Summary and Responsibilities

Are you a highly experienced and meticulous professional with a deep understanding of healthcare regulations, patient safety, and accreditation standards? Virginia Mason Franciscan Health (VMFH) is seeking a dedicated Regulatory Compliance Program Manager to provide essential operational support and strategic coordination for our Patient Safety, Accreditation, and Licensing programs.

This critical role ensures that all facets of patient safety are identified and integrated into comprehensive plans, and that our assigned hospitals and clinics consistently align with The Joint Commission (TJC) standards, as well as state and federal regulations. Join us in our commitment to continuous readiness and the highest standards of patient care!

EVERY DAY, YOU WILL:

+ **Strategic Program Integration:** Provide operational support and overall strategic implementation for Patient Safety and Accreditation and Licensing programs, ensuring a cohesive and comprehensive approach.

+ **Compliance Leadership:** Ensure assigned hospitals and clinics are continuously aligned with The Joint Commission (TJC) standards and all applicable state and federal regulations.

+ **Continuous Readiness Facilitation:** Drive ongoing regulatory compliance activities through extensive rounding and engagement with both clinical and non-clinical departments across VMFH facilities.

+ **Policy & Procedure Implementation:** Oversee the effective implementation of policies and procedures to ensure regulatory adherence.

+ **Survey Preparedness & Management:** Lead and coordinate all aspects of survey preparation, manage survey processes, and ensure diligent follow-up on findings.

+ **Vulnerability Assessment & Reporting:** Proactively assess standards compliance, identify potential vulnerabilities, and report findings to key stakeholders with clear actionable insights.

+ **Training & Education:** Develop and conduct targeted training programs for management, educators, and staff in response to identified or potential deficiencies, fostering a culture of compliance.

+ **Incident Review & Trend Analysis:** Assist in the review and trending of incident report information, providing valuable quality data for internal quarterly reviews and ongoing physician performance evaluations.

+ **Guidance & Coaching:** Offer expert guidance and coaching to management, empowering them to achieve and maintain a state of continuous readiness for all licensure, accreditation, and certification programs, as well as ensuring ongoing compliance with state and federal rules and regulations.

TO BE SUCCESSFUL IN THIS ROLE, YOU WILL DEMONSTRATE:

+ **Regulatory Expertise:** In-depth knowledge of The Joint Commission (TJC) standards, CMS regulations, state licensing requirements, and other relevant federal healthcare compliance mandates.

+ **Patient Safety Acumen:** Strong understanding of patient safety principles, methodologies, and quality improvement processes.

+ **Analytical & Problem-Solving:** Exceptional analytical ability to assess complex situations, identify compliance risks, and develop effective, practical solutions.

+ **Communication & Influence:** Excellent verbal, written, and presentation skills to effectively communicate complex regulatory information to diverse audiences, from frontline staff to senior leadership.

+ **Coaching & Mentoring:** Proven ability to provide effective guidance, coaching, and training to staff and management, fostering self-sufficiency in compliance.

+ **Organizational Skills:** Superior organizational abilities to manage multiple projects, priorities, and deadlines across various facility departments.

+ **Proactive Approach:** A strong sense of initiative and a proactive approach to identifying and addressing compliance challenges.

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 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 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 RN 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.

Pay Range

$49.78 - $74.05 /hour

We are an equal opportunity/affirmative action employer.