Regulatory Compliance Manager
Genesis HealthCare System
Zanesville, OH 43701, USA
Published 3 weeks ago
Business Compliance
GENESIS HEALTHCARE SYSTEM
In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an 'owner' of Genesis and keep our patients at the center of everything we do - always.
Position Details:
Work Shift:
Day Shift (United States of America)
Scheduled Weekly Hours:
40
Department:
Corporate Integrity
Overview of Position:
The Regulatory Compliance Manager reports to the Director of Corporate Integrity and is responsible for overseeing all aspects of regulatory and accreditation compliance across Genesis HealthCare System. This leadership role ensures continuous readiness for surveys, maintains system-wide compliance with accrediting bodies-the Accreditation Commission for Health Care (ACHC) and Commission on Accreditation of Rehabilitation Facilities (CARF)-and regulatory agencies, and provides strategic support for the Imprivata platform to enhance healthcare identity management and data security.
ESSENTIAL DUTIES
1. Directs and manages compliance with all federal, state, and local regulatory requirements for inpatient and outpatient services.
2. Oversees all accreditation activities, including CARF, ACHC, Centers for Medicare & Medicaid Services, Standards and Conditions of Participation, and the Ohio Department of Health, ensuring ongoing readiness and successful survey outcomes.
3. Leads survey preparedness initiatives, including gap analyses, action plan development, and post-survey corrective actions.
4. Supervises the Accreditation Planning Team, ensuring regular updates and education for leadership and staff on regulatory changes.
5. Maintains strong working relationships with accrediting and regulatory agencies, legal services, senior leadership, and medical staff.
6. Prepares and submits accreditation applications and documentation for all hospital-based locations.
7. Oversees the implementation and ongoing support of the Imprivata platform, collaborating with IT and clinical leaders to ensure secure, efficient access to healthcare data and compliance with identity management standards.
8. Ensures Imprivata is leveraged to streamline clinician workflows, enhance data security, simplify password management, and support HIPAA compliance.
9. Provides leadership and guidance to compliance staff, fostering a culture of continuous improvement and regulatory excellence.
10. Delivers regulatory compliance presentations and training across the organization.
11. Conducts and reviews audits, assessments, and regulatory research, reporting findings to the Director and executive leadership.
12. Participates in and leads relevant committees to communicate regulatory guidelines and best practices.
13. Other duties as assigned by the Director of Corporate Integrity.
QUALIFICATIONS
1. Bachelor's degree in healthcare, nursing, or related field.
2. Licensed in the state of Ohio as a Registered Nurse (if applicable).
3. Minimum three (3) years of progressive experience in healthcare compliance, accreditation, or quality management, including leadership responsibilities.
4. Demonstrated experience with accreditation processes.
5. Experience supporting or managing healthcare identity or similar management platforms.
6. Strong interpersonal, leadership, analytical, and communication skills.
7. Ability to work independently and manage multiple priorities in a dynamic environment.
PATIENT CENTERED CARE & BEHAVIORAL EXPECTATIONS
1. Living the Genesis Mission, Vision and Values:
• Performs work in a manner that is quality focused.
• Treats patients, co-workers, visitors and volunteers with courtesy, compassion, empathy and respect.
• Results oriented and focused on achievement of objectives.
• Acknowledges and responds to the diversity of people and the situation.
• Encourages peers (others) to be owners of change.
• Always makes the effort to anticipate and exceed customer needs and expectations.
• Possesses the ability to engage others with patience and understanding.
• Acts in a manner that creates positive first and lasting impressions.
• Demonstrates the ability to own issues until they are resolved.
2. Patient Centered Care (patients/families, physicians, co-workers, all other internal/external customers)
• Introduces self and role...connects with everyone.
• Communicates effectively (i.e. advising others of actions, pertinent information, time durations, etc.) and asks for feedback.
• Asks for and anticipates needs and concerns of others.
• Maintains a positive work environment for staff and a healing environment for patients (i.e. safe, clean, quiet, etc.)
• Maintains the dignity and privacy of each person; manages confidential/sensitive information appropriately.
• Responds to requests in an appropriate and timely manner.
• Exits patient/customer encounters courteously, asking if there are additional needs that can be addressed.
3. Promotes Patient and Employee Safety
• Demonstrates safe Patient Handling (i.e. transfers, transport, care administration, nutrition, medication, etc.)
• Demonstrates safe Materials Handling (i.e. appropriate use and disposal of chemicals, infectious wastes, etc.)
• Demonstrates appropriate knowledge of Infectious Disease precautions and use of proper protective equipment
• Demonstrates Slips/Trips and Falls Awareness.
• Actively contributes to maintaining a safe, clean and quiet environment.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Works in an office environment.
2. Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds, and occasionally lift or move up to 50 pounds.
3. Vision abilities required include; up close vision, peripheral vision, depth perception and the ability to adjust focus.
4. Answers phones, uses a personal computer, scanner, copier, fax, which requires finger dexterity.
5. May occasionally bend, reach, push, pull, stoop kneel, crouch or crawl.
6. Employee may be required to travel to other departments/floors or travel to other locations.
This description reflects in general terms the type and level of work performed. It is not intended to be all-inclusive, nor portray the specific duties of any one incumbent.
Thank you for your interest in employment at Genesis. Genesis is committed to being an equal opportunity employer. Selection of applicants for employment is based only on qualifications and the requirements of a specific job.
In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an 'owner' of Genesis and keep our patients at the center of everything we do - always.
Position Details:
Work Shift:
Day Shift (United States of America)
Scheduled Weekly Hours:
40
Department:
Corporate Integrity
Overview of Position:
The Regulatory Compliance Manager reports to the Director of Corporate Integrity and is responsible for overseeing all aspects of regulatory and accreditation compliance across Genesis HealthCare System. This leadership role ensures continuous readiness for surveys, maintains system-wide compliance with accrediting bodies-the Accreditation Commission for Health Care (ACHC) and Commission on Accreditation of Rehabilitation Facilities (CARF)-and regulatory agencies, and provides strategic support for the Imprivata platform to enhance healthcare identity management and data security.
ESSENTIAL DUTIES
1. Directs and manages compliance with all federal, state, and local regulatory requirements for inpatient and outpatient services.
2. Oversees all accreditation activities, including CARF, ACHC, Centers for Medicare & Medicaid Services, Standards and Conditions of Participation, and the Ohio Department of Health, ensuring ongoing readiness and successful survey outcomes.
3. Leads survey preparedness initiatives, including gap analyses, action plan development, and post-survey corrective actions.
4. Supervises the Accreditation Planning Team, ensuring regular updates and education for leadership and staff on regulatory changes.
5. Maintains strong working relationships with accrediting and regulatory agencies, legal services, senior leadership, and medical staff.
6. Prepares and submits accreditation applications and documentation for all hospital-based locations.
7. Oversees the implementation and ongoing support of the Imprivata platform, collaborating with IT and clinical leaders to ensure secure, efficient access to healthcare data and compliance with identity management standards.
8. Ensures Imprivata is leveraged to streamline clinician workflows, enhance data security, simplify password management, and support HIPAA compliance.
9. Provides leadership and guidance to compliance staff, fostering a culture of continuous improvement and regulatory excellence.
10. Delivers regulatory compliance presentations and training across the organization.
11. Conducts and reviews audits, assessments, and regulatory research, reporting findings to the Director and executive leadership.
12. Participates in and leads relevant committees to communicate regulatory guidelines and best practices.
13. Other duties as assigned by the Director of Corporate Integrity.
QUALIFICATIONS
1. Bachelor's degree in healthcare, nursing, or related field.
2. Licensed in the state of Ohio as a Registered Nurse (if applicable).
3. Minimum three (3) years of progressive experience in healthcare compliance, accreditation, or quality management, including leadership responsibilities.
4. Demonstrated experience with accreditation processes.
5. Experience supporting or managing healthcare identity or similar management platforms.
6. Strong interpersonal, leadership, analytical, and communication skills.
7. Ability to work independently and manage multiple priorities in a dynamic environment.
PATIENT CENTERED CARE & BEHAVIORAL EXPECTATIONS
1. Living the Genesis Mission, Vision and Values:
• Performs work in a manner that is quality focused.
• Treats patients, co-workers, visitors and volunteers with courtesy, compassion, empathy and respect.
• Results oriented and focused on achievement of objectives.
• Acknowledges and responds to the diversity of people and the situation.
• Encourages peers (others) to be owners of change.
• Always makes the effort to anticipate and exceed customer needs and expectations.
• Possesses the ability to engage others with patience and understanding.
• Acts in a manner that creates positive first and lasting impressions.
• Demonstrates the ability to own issues until they are resolved.
2. Patient Centered Care (patients/families, physicians, co-workers, all other internal/external customers)
• Introduces self and role...connects with everyone.
• Communicates effectively (i.e. advising others of actions, pertinent information, time durations, etc.) and asks for feedback.
• Asks for and anticipates needs and concerns of others.
• Maintains a positive work environment for staff and a healing environment for patients (i.e. safe, clean, quiet, etc.)
• Maintains the dignity and privacy of each person; manages confidential/sensitive information appropriately.
• Responds to requests in an appropriate and timely manner.
• Exits patient/customer encounters courteously, asking if there are additional needs that can be addressed.
3. Promotes Patient and Employee Safety
• Demonstrates safe Patient Handling (i.e. transfers, transport, care administration, nutrition, medication, etc.)
• Demonstrates safe Materials Handling (i.e. appropriate use and disposal of chemicals, infectious wastes, etc.)
• Demonstrates appropriate knowledge of Infectious Disease precautions and use of proper protective equipment
• Demonstrates Slips/Trips and Falls Awareness.
• Actively contributes to maintaining a safe, clean and quiet environment.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Works in an office environment.
2. Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds, and occasionally lift or move up to 50 pounds.
3. Vision abilities required include; up close vision, peripheral vision, depth perception and the ability to adjust focus.
4. Answers phones, uses a personal computer, scanner, copier, fax, which requires finger dexterity.
5. May occasionally bend, reach, push, pull, stoop kneel, crouch or crawl.
6. Employee may be required to travel to other departments/floors or travel to other locations.
This description reflects in general terms the type and level of work performed. It is not intended to be all-inclusive, nor portray the specific duties of any one incumbent.
Thank you for your interest in employment at Genesis. Genesis is committed to being an equal opportunity employer. Selection of applicants for employment is based only on qualifications and the requirements of a specific job.