Providence Health & Services Program Manager of Regulatory Compliance in Anchorage, Alaska


Providence is calling a Program Manager of Regulatory Compliance in Quality Improvement, Shift to Providence Alaska Medical Center in Anchorage, Alaska - Full-time

The Program Manager of Regulatory Compliance will be a healthcare professional providing structure to facilitate The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) survey process for the PAMC accredited campuses, who will also collaborate with the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) to achieve system safety and quality goals.

In this position you will:

  • Be responsible for continual staff and organizational readiness with regulatory compliance with TJC standards and CMS conditions of participation (COP). Work with clinical leaders, coordinate PAMC staff tracer activities to assure ongoing survey readiness. Maintain regular contact with the PH&S core survey team.

  • Maintain monthly tracer team activities. Recruit and train new members for the tracer team to maintain adequate membership to identify areas of improvement for continual regulatory survey readiness.

  • Be responsible for the assessment and reporting of organization performance on national patient safety goals (NPSG). Works directly with leadership to ensure organization-wide awareness/education of patient safety performance gaps and that action is taken to ensure the safe care of every patient served. Respond to reported patient safety concerns identified internally or by external agencies and provide a written plan of action as requested.

  • Collaborate with the Regulatory Compliance Coordinator to develop and maintain policies and procedures to adhere to all regulatory requirements. Facilitate the Policy, Protocols and Guidelines committee in conjunction with the Regulatory Compliance Coordinator.

  • Facilitate at least one high-risk process for proactive risk assessment (e.g. Healthcare Failure Mode and Effects Analysis) every 18 months.

  • Work collaboratively with hospital administration, and clinical and non-clinical departments and teams to develop and implement performance goals, initiatives and action plans to support regulatory compliance.

  • Collaborate with the Risk Management department in specific event review and resolution, consultation with department managers, facilitation of department and multidisciplinary teams, and proactive risk analysis of systems related to patient safety.

  • Chair the Leadership Accreditation and Safety Review (LASR) meetings; participates in meetings/committees as an ad hoc member for topics related to regulatory compliance such as Operations Council, Community Ministry Boards Quality Improvement Subcommittee (QIS), Leadership Council, and Clinical Leadership meetings.


Required qualifications for this position include:

  • Bachelor’s degree in healthcare related field or RN with requirement to obtain BSN within 24 months of hire.

  • Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certified Professional (HACP), or Joint Commission Certified Professional (CJCP) required, or obtained within 12 months of hire

  • Current, non-encumbered health related licensure/certification (e.g. nursing, pharmacy, radiology, respiratory therapy, etc…)

  • Clinical acute care experience

  • 2 years of progressive management experience

  • Experience in designing, implementing, and leading clinical outcome improvement programs

  • Previous experience with Joint Commission survey coordination at facility level

  • Excellent oral and written communication skills,

Preferred qualifications for this position include:

  • Master’s degree in health care related field

About Providence Alaska Medical Center

Providence Health & Services Alaska is among nation’s best employers for healthy lifestyles! The National Business Group on Health, a non-profit association of large U.S. employers, has honored Providence Alaska for its commitment and dedication to promoting a healthy workplace and encouraging our caregivers (employees) and families to support and maintain healthy lifestyles. Mountain-Pacific Quality Health has awarded Providence Alaska Medical Center with its Quality Achievement Award for high-quality care in the areas of heart attack, heart failure, pneumonia and surgical infection prevention. This is the highest honor awarded by Mountain-Pacific.

As the state’s largest hospital, Providence Alaska Medical Center provides full-service, comprehensive care to all Alaskans, a role unmatched by any other in the state. Within our community, you will find top notch ski resorts, kayaking, and wildlife. Enjoying the outdoors is just one of many reasons to live in and explore Alaska!

We offer a full comprehensive range of benefits - see our website for details

Our Mission

As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.

About Us

Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Project & Program Management (Clinical)

Location: Alaska-Anchorage

Req ID: 165270