Program Manager Ambulatory Regulatory and Accreditation - Administration

Program Manager Ambulatory Regulatory and Accreditation•Administration Christus Health United States, Mexico, Alamogordo 1401 East 10th Street (Show on map) May 11, 2026

Description Summary:

In a High Reliability Organization, the Program Manager Regulatory and Accreditation, provides support to leadership under the direction of the Director for Ambulatory Quality Management. Manages system-wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Uses HRO Principles, Universal Skills, and Reliability Science to facilitate the system's standardized processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities. Serves as a liaison to leadership in quality and clinical risk management to implement change. Provides guidance on how to facilitate the corrective action plans developed by leaders from the areas that were cited. Provides coaching of members of the leadership team on regulatory preparedness. Supports the policy, procedure, and document governance that guides safe, evidence-based practice of patient care. Works on performance improvement projects as directed by the Director Ambulatory Quality Management Knowledgeable on accreditation agencies such as the CMS. Supports policy implementation for processes and programs facilitating regulatory and accreditation compliance with federal and state laws and regulations.

Responsibilities:

Meets expectations of the applicable One

CHRISTUS

Competencies:

Leader of Self, Leader of Others, or Leader of Leaders. Must communicate effectively to different audiences. Must be proficient in computer skills using EXCEL, PowerPoint, MSOffice, and Flowchart tools. Knowledgeable on High Reliability Principles, HRO Universal Skills, HRO Reliability Science preferred. Must have knowledge of PDSA methodology.

Source:

NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains Quality Leadership and Integration•Advance the organization's commitment to healthcare quality through collaboration, learning opportunities, and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives.

Domain Level:

Advanced Performance and Process Improvement•Use performance and process improvement (PPI), project management, and change management methods to support operational and clinical quality initiatives, improve performance, and achieve organizational goals.

Domain Level:

Advanced Population Health and Care Transitions•Evaluate and improve healthcare processes and care transitions to advance the efficient, effective, and safe care of defined populations.

Domain Level:

Proficient Health Data and Analytics•Leverage the organization's analytic environment to help guide data-driven decision-making and inform quality improvement initiatives.

Domain Level:

Advanced Regulatory and Accreditation•Direct organization-wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities.

Domain Level:

Advanced Patient Safety•Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm.

Domain Level:

Advanced Quality Review and Accountability•Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement.

Domain Level:

Advanced Professional Engagement•Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field.

Domain Level:

Proficient Job Requirements:

Education/Skills Bachelor's Degree of Science in Nursing, or other clinical degree specialties required Master's degree preferred Experience Five years of healthcare experience required Three years of quality management experience required Licenses, Registrations, or Certifications Certified Professional in Healthcare Quality (CPHQ) is required at or within 1 year of hire In accordance with the

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Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

8AM•5

PM Monday-Friday Work Type:

Full Time