Manager - Regulatory Compliance

Lebanon, PA | Professional | Tracking Code: 61506

General Summary


Under the general supervision of the Director-WSH Accreditation and Licensure, provides direction and leadership by coordinating activities designed to achieve and maintain compliance with the PA Department of Health, hospital accreditation organizations, CMS Conditions of Participation and the Department of Human Services regulations (accreditation standards) directly for the Hospital and for all outpatient centers/practices that are licensed by the Hospital. Performs a variety of clinical audits, analysis of the data as well as ensures compliance with regulatory audits. Acts as Coordinator for on-site surveys and works in collaboration with others to facilitate system process and outcome improvements. Working with clinical teams and facilities staff, determines root cause for identified defects and deficiencies and prepares standard work and policy recommendations as appropriate. Spreads information through communication forums such as WellSpan’s Quality Leadership Team (QLT) and Accreditation Leadership Team (ALT).


Duties and Responisbilities


Ensures that all standards related to licensure and hospital accreditation standards are being met.

Works closely with leadership and appropriate staff to coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.

Keeps abreast of appropriate regulatory agency requirements related to accreditation and licensure.

Educates others in interpretation of standards and assists as needed in planning improvements/compliance.

Initiates mock tracers as well as analyzing the data, reporting results to the appropriate oversight committee(s), and plans intervention activities for improvement, as appropriate.

Facilitates the Survey Readiness Committee and related activities.

Compiles data for and prepares regularly scheduled or special reports, analyses and statements.

Develops and oversees the implementation of corrective action plans to address survey findings.

Keeps abreast of appropriate regulatory agency requirements related to accreditation.

Utilizes findings to initiate improvement and Tracer activities as educational opportunities for staff.

Provides ongoing reports and updates of existing and potential regulatory compliance issues to the Director, senior leadership, hospital Board(s) and other individuals and groups as directed.

Knowledgeable about Lean methodologies and uses Lean Daily Management System tools to implement effective process improvements.

Is an active participant in the Hospital Environmental Safety Committee, Emergency Management Committee, and Environment of Care Rounds.

Coordinates and disseminates information to all hospital employees regarding accreditation and licensure, providing educational guidance as appropriate.

Develops, establishes and implements goals, objectives, and policies and procedures for department and hospital operations, which guide and support the provision of services.

Continuously assesses and improves the department, entity’s performance. Maintains appropriate quality control/assessment programs (if applicable).




3 years experience of Government Regulations; Healthcare and Regulatory Affairs

Clinical experience related to Patient Safety

Current and active RN license in PA preferred

Bachelor's Degree

Lean methodologies preferred,

Demonstrated leadership skills and ability to work independently;

Demonstrated knowledge of health care and regulatory affairs;

Must have a global view of the WellSpan Health vision and mission;

Analytical, inquisitive, persistent and detail-minded

Similar Opportunities

Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Formed in 1813, Lebanon is a quaint city of 25,700 residents. The area, rich in heritage and the small-town charm of yesteryear, features sites on the National Register of Historic Places, museums, scenic parks and recreation facilities, performing arts theaters, artists' studios, a farmers' market and dining establishments for all tastes.

Life in Lebanon County offers affordable housing and options for pursuing higher education. Residents can find local employment in manufacturing, retail, arts and entertainment, healthcare and service sectors. Located in southcentral Pennsylvania, Lebanon is within an easy driving distance to Harrisburg, Lancaster, Reading and York. (Patient population: 140,000)