Job Duties:The Johns Hopkins Surgery Centers Series (JHSCS) Regulatory Affairs Manager focuses on regulatory compliance initiatives to support continuous patient readiness, quality and patient safety in the Ambulatory Surgery Center (ASC) environment. The Manager concentrates on oversight of ASC accreditation and certification processes, including: 1) interpretation and guidance on applicability of standards, regulations and law in consultation with JHHS legal counsel as necessary; 2) development, implementation and monitoring of corrective actions; 3) education and communication; and 4) survey operations, including but not limited to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and the state Office of Healthcare Quality (OHCQ).

The JHSCS Regulatory Affairs Manager is knowledgeable about interpreting and implementing ASC regulatory standards to provide internal support with regulatory processes, including but not limited to: (1) coordinating onsite surveys by external regulatory agencies; (2) developing, implementing and monitoring of action plans, including relevant policy and/or documentation revision and staff/leadership education; (3) coordinating and overseeing a series-wide continuous readiness program; (5) managing ongoing internal efforts at improving overall efficiency and effectiveness of services and functions.

Full Time (40 hours)

8:00am – 5:00pm

Position home location – Keswick but will rotate to all six (6) surgical centers.


Completion of an accredited Nursing (RN or LPN), Physician Assistant (PA), or Bachelor’s Degree in related or allied healthcare field required. Master’s Degree preferred.


Licensed in the State of Maryland as a Registered Nurse (RN), Physician Assistant (PA), Licensed Practical Nurse (LPN) or licensure in a related healthcare position, as applicable.


Minimum of 5 years of experience in ASC regulatory compliance, performance improvement, patient safety and/or project management. Experience in related or allied health care field collecting and analyzing data, preparing reports, identifying and solving problems and conducting educational programs with hospital staff, etc. greatly preferred.


Current knowledge of The Joint Commission (TJC) and other regulatory standards pertaining to ASCs, Center for Medicare and Medicaid Services (CMS) Conditions for Coverage for ASCs, PI tools and techniques, and computerized medical record documentation required. Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes. Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution. Basic knowledge of medical records auditing and adequacy of documentation. Awareness of regulatory, licensing and accreditation standards. Proficient with Microsoft Office, Microsoft Excel and other project management applications. Ability to formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to regulatory compliance

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Medicine

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