Regulatory Compliance & Accreditation Manager

Position Summary

The Regulatory Compliance & Accreditation Manager is responsible for maintaining organizational readiness for AASM and The Joint Commission accreditation, CMS/Medicare requirements, and applicable state regulatory obligations. This role develops and maintains compliance systems that support safe, high-quality care, payer eligibility, and scalable operations across sleep diagnostic locations and services.

Essential Duties and Responsibilities
Accreditation Management

• Serve as the primary operational lead for AASM and The Joint Commission accreditation, renewal, expansion, and survey-readiness activities.
• Maintain an enterprise accreditation calendar that tracks application deadlines, renewal dates, required submissions, site visits, corrective-action plans, and leadership reporting.
• Interpret accreditation standards and convert them into operational policies, workflows, forms, checklists, and staff-training requirements.
• Coordinate preparation for announced and unannounced surveys, including mock surveys, evidence collection, staff interview preparation, tracer activities, and executive briefings.
• Own survey response and post-survey remediation processes; develop corrective-action plans, assign accountable owners, validate completion, and monitor sustained compliance.
• Maintain complete, current accreditation files and supporting evidence for each applicable entity, site, and service line.

Regulatory & CMS Compliance

• Monitor and assess changes to CMS requirements, Medicare coverage rules, Local Coverage Determinations (LCDs), billing articles, Medicare Administrative Contractor guidance, and relevant payer policies affecting sleep testing, IDTFs, home sleep testing, remote monitoring, and related services.
• Partner with Revenue Cycle, Clinical Operations, Medical Directors, Credentialing, and Legal/Compliance to translate regulatory requirements into documented operational and billing controls.
• Assess the regulatory impact of new services, markets, technologies, referral models, clinical workflows, and care-delivery sites before implementation.
• Establish processes to verify and retain required documentation supporting coverage, medical necessity, supervision, ordering, credentialing, and accreditation requirements.
• Escalate material regulatory, accreditation, patient-safety, reimbursement, or licensure risks to executive leadership promptly.

State Regulatory Oversight

• Maintain a state-by-state regulatory matrix covering facility licensure, professional licensure, scope-of-practice requirements, diagnostic testing rules, telehealth requirements, registration obligations, and reporting requirements.
• Coordinate initial and renewal applications, filings, inspections, and responses to inquiries from state agencies and other regulators.
• Partner with Operations and People teams to ensure staff qualifications, training, supervision, and delegated duties meet state-specific requirements.
• Support due diligence and regulatory readiness for new market entry, acquisitions, site openings, and service expansions.

Compliance Program Operations

• Develop, maintain, and periodically revise policies and procedures required by accreditation standards, CMS requirements, and state regulations.
• Lead a risk-based internal audit program, including audit tools, findings reports, corrective-action tracking, and trend analysis.
• Manage compliance education for clinical, operational, and administrative employees; maintain training records and competency documentation.
• Establish dashboards and reporting for accreditation status, audit results, deficiencies, corrective-action aging, policy review status, and emerging regulatory risks.
• Collaborate with Quality, Infection Prevention, Privacy, Safety, Credentialing, IT, and Clinical Leadership on cross-functional compliance initiatives.
• Promote a culture in which employees identify, report, and resolve compliance concerns without retaliation.

Required Qualifications

• Bachelor’s degree in healthcare administration, nursing, public health, business, or related field; equivalent relevant experience may be considered.
  5+ years of healthcare regulatory, accreditation, quality, compliance, or operations experience.
• Direct experience preparing for or maintaining AASM, The Joint Commission, ACHC, CMS certification, or comparable healthcare accreditation/regulatory programs.
• Working knowledge of Medicare coverage and documentation requirements, including the distinction between CMS rules, MAC LCDs/articles, and commercial-payer requirements.
• Demonstrated ability to interpret standards, conduct gap assessments, create corrective-action plans, and drive cross-functional implementation.
• Exceptional organizational, project-management, written-communication, and stakeholder-management skills.
• Ability to manage sensitive information with sound judgment, discretion, and attention to detail.

Preferred Qualifications

• Experience with multi-site healthcare operations, diagnostic testing, ambulatory care, sleep medicine, DME, IDTF, or telehealth strongly preferred.
• Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), or comparable credential.
• Clinical licensure or prior experience in sleep medicine, diagnostic testing, ambulatory care, or revenue-cycle compliance.
• Experience managing accreditation across multiple legal entities, service lines, or states.
• Familiarity with Epic or other EHR workflows, document-control systems, and compliance/audit-management platforms.
   

Physical and Work Requirements
This is a remote position requiring prolonged periods of computer-based work, virtual meetings, document review, and written communication.

Employment Details (Role-Specific)

Pay Rate / Salary Range: $70,000 - $120,000

Job Type: Full-time

Schedule: Standard Business Hours

Work Location: Remote

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Equal Opportunity Employer
Persante Health Care is an Equal Opportunity Employer committed to building a diverse and inclusive workforce. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected status.