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USPI Manager, Regulatory & Accreditation - 75% Nationwide Travel - (REMOTE)

Job ID: 2305000113 Date posted: 10/31/2022 Location: Dallas, Texas Facility: Tenet HealthSystem Medical Inc
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Job Details

United Surgical Partners International (USPI) has an immediate opening for a Manager, Regulatory and Accreditation to support the enterprise. This position will require a high percentage of nationwide travel – minimum of 39 weeks per year. Position will support the USPI corporate office located in Dallas, TX.

Manager, Regulatory and Accreditation is responsible for assessing, developing, educating, implementing, monitoring, and leading the USPI Regulatory and Accreditation activities within the company. This includes preparation and survey readiness. The position develops and implements processes for current safe practices in USPI. The Manager, Regulatory and Accreditation work closely with other corporate departments, groups, and facilities for collaboration and synergy around identified priorities.

  • Develops, educates, implements, monitors, and leads, USPI, regulatory requirements and accreditation standards, goals, and targets through collaboration with corporate departments and the Director Quality Patient Safety (DQPS).
  • Is a leader for the Clinical Operations Department in the formulation of USPI regulatory and accreditation related goals and targets.
  • Assists with the development of the USPI strategy and tactics for regulatory and accreditation preparation and successful surveys
  • Tracks progression and sustainment of the USPI regulatory and accreditation strategy and tactics per standardized reporting process.
  • Provides input for strategic development, planning and implementation of USPI Clinical Operations Regulatory and Accreditation activities.
  • Provides leadership and expertise in methods of preparation and sustainment of regulatory requirements and accreditation standards.
  • Provides leadership and expertise in methods of performance improvement.
  • Coordinates and collaborates with USPI leaders on activities related to the development, implementation, improvement of and adherence to the organization’s policies and procedures covering the scope of regulatory requirements and accreditation standards
  • Supports USPI’s preparation for surveys (i.e., State, TJC, CMS and others)
  • Conduct formal facility reviews.
  • Supports the formulation of responses [plans of correction] from surveyors, electronic communication, or third-party payers under the direction and approval of the USPI Clinical Operations Department as needed.
  • Prepares reports which displays the results of regulatory and accreditation activities and updates the USPI regulatory requirements and accreditation standards plans and strategies as needed.
  • Remains current concerning industry-wide, leading practices and evaluates practices for implementation in USPI.
  • Demonstrates ethical behavior in decision-making, performance of job responsibilities while maintaining confidentiality regarding patient information, quality, performance, and peer review information.
  • Facilitates, supports, and organizes process improvement and provides staff support services to such teams.
  • Develops USPI policies and procedures for areas of responsibility.
  • Develops and uses USPI methods, tools, and other resources for regulatory and accreditation preparedness and sustainment.
  • Develops and presents educational material to various audiences based on identified or trending regulatory and accreditation issues.


Education, training and background for the successful candidate include:

  • Bachelor’s degree required, with experience in regulatory requirements, accreditation standards, and process improvement.
  • Requires an advanced degree in a health-related field (Masters) with five years of relevant facility management experience.
  • At least 10 years of experience leading a multi-hospital system Regulatory and Accreditation program.
  • Advanced knowledge of environment of care/life safety regulations in surgical facilities (or ambulatory surgery environment).
  • Ability to travel nationally up to 75% required (minimum). Selected candidates will be required to pass Motor Vehicle Record check.
  • Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.
  • Knowledge of TJC, CMS COP’s, and other federal and state requirements regulatory standards.
  • Relevant experience in healthcare/clinical setting.
  • Strong organizational, written, and presentation skills.


  • Certified Joint Commission Professional (CJCP) or Certified Professional Healthcare Quality (CPHQ) within twelve months of hire date.


  • Skilled at developing and conducting educational presentations.
  • Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for USPI facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
  • Prepares written reports of clinical and operational survey findings.
  • Skilled in developing corrective action plans, provide educational programs, monitor implementation of action plan and other oversight activities through follow-up visits to facilities as needed, and provide guidance on regulatory and accreditation communications as needed.
  • Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.
  • Knowledgeable in the areas of peer review, risk management, patient safety, infection control prevention and reporting
  • Polished communicator (written, verbal and presentation skills) with many levels of key stakeholders from the board level to the point of care staff.
  • Expert with working, leading, following, coordinating, and managing activities to driving change within USPI to achieve strategic initiatives for clinical / operational initiatives related to regulatory accreditation.
  • Identifies potential or actual regulatory/accreditation risk issues at facilities in the assigned groups that can impact regulatory/accreditation compliance and pose a financial or reputational risk to the facility or company and immediately reports those findings to the USPI Clinical Operations Department to address the issue.


  • PC based Word and Excel spreadsheet programs
  • Industry publications as they relate to Quality and other areas, as applicable, such as Safety, Risk Management, etc.
  • Electronic Health Record
  • eSRM (Risk Management System)
  • Balanced Score Card / Clinical Operations Scorecard
  • SharePoint
  • AMP with Tracers

USPI complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program. Follow the link below for additional information.


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