Job Description

Job Title: Manager, Regulatory and Accreditation - UPMC Mercy
Job ID: 57316918
Status: Full-Time
Regular/Temporary: Regular
Hours: 40
Shift: Day Job
Facility: UPMC Mercy
Department: Quality Management
Location: 1400 Locust Street, Pittsburgh PA 15219


UPMC is currently hiring a Full Time Manager of Regulatory and Accreditation within the Quality Management team at Mercy Hospital!

This position will build positive relationships internally and externally with regulators, directors, executives, and front line staff. They will work with the VPMA, VP Patient Care, CNO, and VP Op to assure the hospital is ready for TJC and DOH inspections. They will need to have an understanding of construction projects along with clinical care.

The Manager of Regulatory and Accreditation is accountable to the Quality and Safety Director for the management of all regulatory compliance programs, including TJC, Department of Health and CMS regulations and standards. In addition, this individual will be responsible for the implementation of risk liability programs and will assist in the planning, developing and monitoring of clinical program services to define risk and liability for the hospital.

  • Acts as a liaison between medical center departments and/or medical staff through the use of a broad range of knowledge on accreditation standards, state and federal regulations and license requirements.
  • Ensure compliance with all Pennsylvania Department of Health regulations.
  • Accountable for the coordination of TJC, DOH and CMS activities and standards. This includes: serving as a liaison, completion of applications for survey, coordination of survey schedules, serving as a consultant on interpretation of standards and strategies to meet the intent of the standards, preparation and submission of any compliance reporting or progress reports, coordination of any unannounced surveys, and providing in-services to staff.
  • Serves as Chairperson of Continuous Readiness Team. Work with committee members and appropriate others to ensure comprehensive medical center wide mechanism to maintain compliance with TJC, DOH and CMS standards. Assist in formulation of corrective action plans and evaluate the effectiveness of these in meeting the intent of the Joint Commission standards. Conducts annual self-assessment of hospital.
  • Works collaboratively with the infection control practitioner to ensure compliance with Act 72.
  • Ensures compliance with non-financial, clinically based CMS requirements.
  • Serve as a resource on a broad range of regulations and standards.
  • Conducts ongoing assessments as to the state of compliance to all applicable regulations and standards. Conducts mock audits around the hospital.
  • Stays abreast of proposed and new regulations and standards and initiates action to ensure compliance.
  • Educate managerial, medical, and clinical staff to regulations and standards to develop an informed and effective health care team.
  • Participates in administrative policy review process to ensure compliance
  • Collaborate with patient safety officer and risk management department as needed
  • Assist in review of Hospital Division and Health System Policies and participates in system wide Regulatory Compliance Committee, as needed.
  • Effectively collaborate and communicates with all levels of the organization and UPMC
  • Acts in a manner that supports the UPMC four core values of quality & safety, care &compassion, dignity & respect, and community. Manages and mentors staff to accordingly to meet or exceed these four core values.


  • Bachelor's degree in Nursing, Health Care Related Field or equivalent. Master's degree preferred.
  • Minimum of 5 years of healthcare experience.
  • Previous experience with Department of Health, TJC compliance activities and risk management.

Licensure, Certifications, and Clearances:
  • Registered Nurse (RN)
  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Salary Range: $34.96 to $59.20 / hour

    Union Position: No

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