Hospital Regulatory Manager

About Us

We are Emerus, the leader in small-format hospitals. We partner with respected and like-minded health systems who share our mission: To provide the care patients need, in the neighborhoods they live, by teams they trust. Our growing number of amazing partners includes Allegheny Health Network, Ascension, Baptist Health System, Baylor Scott & White Health, ChristianaCare, Dignity Health St. Rose Dominican, The Hospitals of Providence, INTEGRIS Health, MultiCare and WellSpan. Our innovative hospitals are fully accredited and provide highly individualized care. Emerus' commitment to patient care extends far beyond the confines of societal norms. We believe that every individual who walks through our doors deserves compassionate, comprehensive care, regardless of their background, identity, or circumstances. We are committed to fostering a work environment focused on teamwork that celebrates diversity, promotes equity and ensures equal access to information, development and opportunity for all of our Healthcare Pros.

Position Overview

The Hospital Regulatory Manager leads and coordinates regulatory readiness efforts across all Emerus markets. The role ensures sustained survey readiness and compliance with federal, state, and local regulations and applicable accreditation standards (e.g., DNV, CMS). This position partners with quality and operational leaders to promote continuous readiness, patient safety, and high-quality care.

Essential Job Functions

• Serve as an expert resource to quality, corporate and market leadership, staff and physicians on accreditation and regulatory requirements
• Monitor and implement regulatory changes and translates requirements into operational guidance with state, federal, and accreditation regulations (e.g. OSHA, CMS, and state-specific healthcare regulations).
• Prepare and submit required documentation to state and federal regulatory agencies and support the documentation and reporting needs for accrediting bodies (e.g., DNV).
• Maintain thorough documentation, reports, and readiness artifacts to support surveys, internal governance, and continuous improvement.
• Ensures policies and procedures reflect current regulatory expectations and organization process.
• Communicates readiness status and progress on accreditation/regulatory initiatives to executive leadership.
• Plan, coordinate, and guide validation tracers, mock surveys, audits, and other assessment activities to evaluate regulatory and accreditation readiness; provide clear feedback and recommendations to leaders.
• Coordinate with Quality Managers to identify areas of vulnerability and risk related to standards and regulations; support corrective action plans to close gaps and sustain compliance.
• Provide education and training for leaders and front line staff on regulatory processes, survey readiness, standards interpretation to new facilities and new markets, as well as with current departments.
• Facilitate follow-up activities and conduct performance improvement projects that may need to extend to all markets.

Other Job Functions

• Attend staff meetings or other company sponsored or mandated meetings as required
• Travel to all facility locations as required
• Performs additional duties as assigned
• Verbal and written communication skills to communicate effectively with diverse populations. 
• Prioritize, organize, and meet tight deadlines for multiple concurrent tasks and team requests; apply leadership experience to manage expectations, flag obstacles and propose solutions in a timely manner. 
• Navigate technical systems: electronic medical records (EMR), registry/case entry tools for state reporting.
• Proficiency with Microsoft Office (Word, Excel, PowerPoint and Outlook), required

Basic Qualifications

• Bachelor’s Degree, required
• 1-3 years’ experience in healthcare regulatory compliance, accreditation, quality or performance improvement
• If Registered Nurse, must have current RN license in state of practice in good standing
• 3+ years related healthcare quality experience, preferred
• Knowledge of Federal, State and required regulatory agency standards related to health care organizations, required
• Proficiency with Microsoft Office (Word, Excel, PowerPoint and Outlook), required
• Position requires fluency in English; written and oral communication