Manager, Regulatory Affairs (RN required)

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Req #: 10324
Division: Quality
Employment Type: Full Time
Shift: Day
Compensation Type: Salaried
Facility: JPOC 1400
Location: 1400 S. Main Street, Fort Worth, TX


Description: The Manager Regulatory Affairs provides guidance and leadership activities aimed at achieving a continuous state of readiness surrounding licensure, accreditation and certification programs, as well as, ensuring ongoing compliance with State and Federal rules/regulations and performance improvement. This position facilitates the coordination of regulatory compliance activities that include assessment of standards compliance, performance improvement activities and with special projects across the department as assigned. The Manager of Regulatory Affairs will provide leadership over the Accreditation Coordinators.
Typical Duties:

  1. Develops direct reports by defining roles/responsibilities and expectations, assigning and communicating performance and promoting professional growth and accountability. Assists team in communicating and aligning work priorities with the organizational vision, mission, values, and service standards.
  2. Prioritizes and allocates staff and resources to accomplish assigned objectives within approved budget parameters.
  3. Recommends and develops policies and procedures for the department. Reviews all departmental policies and procedures on an ongoing basis to determine current Joint Commission compliance.
  4. Provides planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of accreditation readiness program components including standard and regulatory compliance, individual and system tracers, to ensure standard compliance is integrated into daily work processes to enhance quality of patient care and appropriateness and timeliness of services.
  5. Provides and maintains regulatory and accreditation requirements expertise and communicates appropriately to staff. Serves as the expert resource in safety, quality improvement, accreditation and regulatory issues to hospital and contract staff, Joint Commission teams and committees.
  6. Facilitates assessments, performance improvement activities, corrective action plans, and/or implementation and evaluation based on mock surveys, tracer activities of Joint Commission preparation activities including, but not limited to Periodic Performance Review (PPR).
  7. Prepares and disseminates accreditation readiness standards updates and other accreditation readiness education strategies.
  8. Oversees development and dissemination of staff education curriculum for the department that supports evidenced based practices.
  9. Performs other related job duties as assigned.



    Required Education and Experience:

  • Bachelor’s Degree in a healthcare related field.
  • Five (5) plus years of experience in healthcare accreditation/regulatory compliance including 2 years of leadership experience.
  • Two (2) years experience working in a healthcare setting preparing staff for accreditation readiness.
  • Required Licensure/Certification/Specialized Training:

  • Experience in healthcare regulatory affairs and/or compliance
  • Preferred Education and Experience:

  • Current licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state.
  • Master’s Degree in Nursing or healthcare related field.
  • Five (5) plus years of experience in healthcare regulatory and accreditation in a large healthcare system.
  • Preferred Licensure/Certification/Specialized Training:

  • Lean Six sigma Green Belt of higher

Location Address:
1400 S. Main Street
Fort Worth, Texas, 76104
United States


JPS Health Network is a $950 million, tax-supported health care system for Tarrant County in North Texas. Licensed for 578 beds, the network includes an acute care hospital and more than 40 community-based clinics, including 19 school-based clinics. John Peter Smith Hospital is home to Tarrant County’s first and only Level 1 Trauma Center, its only psychiatric emergency services site and has the largest hospital-based family medicine residency program in the nation. Our network employs more than 6,500 people.

Acclaim is our multispecialty medical practice group. Acclaim has over 300 providers serving the JPS Health Network in specialties ranging from primary care to general surgery and trauma. The Acclaim group has been formed around a common set of incentives and expectations supporting the operational, financial and clinical performance
outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

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