Accreditation and Regulatory Compliance Mgr

With traumatic brain injury, life changes in an instant. For us, there is no greater reward than easing human suffering and helping people put their lives back together. As a Facility Manager you will play a critical role in transforming lives and helping individuals regain their independence and quality of life.

At CNS, we are a community of "PATHfinders" who work together to find every path possible for our patients to reach their maximum independence and quality of life. We create a supportive work environment through selflessness, innovation, and hard work. We take work very seriously, but we also enjoy a great atmosphere of fun and professional development, and we are committed to promoting a rich environment for each other to thrive through collaboration and empowerment.

Responsibilities

The Accreditation and Regulatory Compliance Manager is responsible for leading the organization’s regulatory and accreditation compliance efforts, ensuring continuous readiness for applicable federal, state, and local regulations, including Health and Human Services (HHS) requirements in both states (TX & CA), CLIA, CARF, and other oversight agencies relevant to our clinical and residential services. This position serves as a subject matter expert and internal resource on all regulatory and accreditation matters, overseeing survey and audit readiness, incident management, process improvements, policy development and leadership collaboration. The Accreditation and Regulatory Compliance Manager provides ongoing education and training to promote a culture of compliance and patient safety. Work is full time during the weekdays with some weekend work, especially when traveling. Work is performed onsite at the administration, clinic, residential locations, and other company facilities. Traveling to other CNS sites is required on a quarterly basis. A high degree of accuracy in documentation and observation, adaptability to a variety of situations, and strong organizational and communication skills is needed for this position

• Regulatory & Accreditation Oversight. Ensure compliance with all applicable state and federal regulations, including Texas and California HHS, CLIA, and CARF standards. Leads all continuous readiness and accreditation efforts, including CARF preparation, site visits, and follow-up reporting. Oversee compliance activities across both clinical and residential settings, ensuring documentation, policies, and procedures are survey ready. Manage all aspects of regulatory inspections, audits, and surveys, acting as the organization’s primary contact and representative during such events.
• Internal Compliance Resource & Expert Proactively monitor changes in federal, state, and accreditation standards, including HHS, CLIA, and CARF regulations. Provide update for executive leadership and operational teams. Serves as a subject matter expert on accreditation, regulatory standards, and best practices interpreting requirements and guiding leadership, clinical and residential teams. Maintains and facilitates awareness of internal policies and consults on the interpretation and interaction of current policies, how they interact with the current climate, and potential changes to regulations or legislation. Ensure that all applicable changes are reflected in updated policies, procedures, training, and operations. Develop and revise compliance policies and procedures in alignment with current laws and standards. Identify compliance risks and lead efforts to mitigate and monitor those risks through audits, education, and system improvements.
• Training & Capacity Building. Develop, implement, and lead compliance training programs tailored to different staff roles (clinical, administrative, residential). Trains and mentor leaders and staff on survey protocols, documentation standards and compliance responsibilities. Conduct regular compliance briefings and updates to staff and leadership on regulatory standards and organizational expectations. Support a culture of continuous learning and readiness related to sustainable compliance strategies and accreditation excellence. Promotes learning in others by proactively providing and / or developing information, resources, advice, and expertise with staff. Support the accreditation and licensing of new program locations, ensuring compliance from planning through activation.
• Audit & Survey Management. Partners with Clinic and Residential Managers to respond to surveyors. Coordinate and lead responses to scheduled and unannounced audits, surveys, and inspections. Manage all follow-up actions, including corrective action plans, documentation submission, and communication with external agencies with input from key Clinic and Residential managers. Conduct mock surveys, internal assessments, to proactively identify risk, gaps and drive continuous improvement.
• Collaborates functionally with Quality Manager, Risk Management, Nursing and Medical Staff, Human Resources and Legal teams to align compliance initiatives and annual reporting.
• Adopts new responsibilities; adapts to and learns from change, challenges, and feedback. Demonstrates flexibility in approaches to work. Champions change and helps others adapt to new regulations and processes.
• Build relationships with cross functional / external stakeholders and internal customers. Listens to, seeks, and addresses feedback. Provides actionable feedback to others and to managers. Facilitates team collaboration to support business outcomes.
• Maintains professional and ethical relationships with staff, patients, patient families and other visitors.
• Attends staff meetings, in services and all scheduled shifts.

Qualifications

Experience and Education :

Benefits Package Includes :

At CNS, we value our employees and offer a comprehensive benefits package to support your well-being and professional growth. Here are some of the benefits you can enjoy as a full-time staff member :

Wisely Financial Services :

As part of our comprehensive benefits package, we are pleased to offer access to Wisely's financial services. These services are designed to provide flexibility and control over your finances, helping you manage your money more effectively and achieve your financial goals. Here are some of the key services offered by Wisely :

Call to Action

Are you passionate about making a difference in people's lives? Join us at CNS and be part of a team that is dedicated to helping individuals with brain injuries find hope and independence. Apply now to become an Accreditation and Regulatory Compliance Manager and start your journey with us today!

I WANT IN!