Program Manager, HR Compliance & Regulatory Audit

Summary

The Program Manager partners closely with Human Resources, Medical Staff Services, Legal, Compliance, Occupational Health, Payroll, Workforce Analytics, and operational leaders to ensure compliance with federal and state employment laws, healthcare regulations, accreditation standards, credentialing requirements, and organizational policies. This role develops audit controls, monitors compliance risks, coordinates corrective action plans, and supports a culture of continuous compliance and operational excellence. Reports to the Director, Total Rewards.

• GENERAL SUMMARY
• The Program Manager, HR Compliance & Regulatory Audits is responsible for developing, implementing, and maintaining Human Resources compliance programs that support regulatory readiness across Children's Hospital of The King's Daughters (CHKD). This position serves as the primary HR lead for workforce-related audits, regulatory reviews, accreditation surveys, licensure compliance, and employment-related regulatory requirements.

• ESSENTIAL DUTIES AND RESPONSIBILITIES
• Audit Coordination & Accreditation Readiness
• Serves as the primary HR coordinator for external and internal audits and regulatory reviews.
• Coordinates workforce-related audits conducted by:
• The Joint Commission and/or DNV Healthcare
• Centers for Medicare & Medicaid Services (CMS)
• Virginia Department of Health
• State licensing agencies
• External auditors and consultants
• Collects, validates, and provides required documentation during surveys and inspections.
• Develops and maintains audit-ready documentation and supporting records.
• Tracks audit findings and corrective action plans through completion.
• License, Certification & Credential Compliance
• Oversees processes to monitor employee licenses, certifications, registrations, and required credentials.
• Partners with Medical Staff Services, Occupational Health, and department leaders to ensure workforce compliance with licensing and certification requirements.
• Develops reporting and tracking mechanisms for license renewals and expirations.
• Investigates license compliance issues and coordinates resolution activities.
• Monitors compliance with mandatory workforce requirements and healthcare certifications.
• Workforce Records & Documentation Management
• Oversees compliance with workforce record retention requirements.
• Develops procedures to ensure employee files and documentation meet regulatory and accreditation standards.
• Conducts periodic audits of personnel records, I-9 documentation, licensure records, and required employee certifications.
• Maintains documentation supporting workforce compliance activities and regulatory reporting.
• HR Policy & Governance
• Leads periodic reviews of HR policies and procedures to ensure regulatory compliance.
• Coordinates with HR leadership and Legal to create and revise policies based on regulatory changes.
• Ensures consistent interpretation and application of HR policies across the organization.
• Supports investigations involving potential compliance concerns.
• Regulatory Reporting & Workforce Compliance Analytics
• Coordinates preparation of workforce-related regulatory reports and compliance submissions.
• Collaborates with Human Resources teams to ensure data integrity.
• Develops dashboards and reporting to monitor:
• License compliance
• Certification completion
• Audit findings
• Corrective action status
• Policy acknowledgements
• Required training compliance
• Identifies trends and recommends risk mitigation strategies.
• Training & Education
• Provides guidance to HR staff and leaders regarding workforce compliance requirements.
• Serves as an internal subject matter expert on HR compliance and workforce regulatory issues.
• LICENSES AND/OR CERTIFICATIONS
• Required Licenses and/or Certifications
• None
• Preferred Licenses and/or Certifications
• SHRM-CP, SHRM-SCP
• PHR or SPHR
• Certified in Healthcare Compliance (CHC)
• Healthcare Human Resources Certification (CHHR)
• Project Management certification
• MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
• Required Education and Experience
• Five (5) years of HR compliance, audit, credentialing, and regulatory experience required.
• Experience coordinating regulatory audits and accreditation surveys required.
• Experience interpreting employment laws, healthcare regulations, and compliance standards required.
• Experience with HRIS, workforce analytics, and compliance reporting systems required.
• Preferred Education and Experience
• Bachelor's degree in Human Resources, Healthcare Administration, Business Administration, Public Administration, Compliance, or related field preferred.
• Experience in a healthcare provider organization is strongly preferred.
• Experience supporting Joint Commission, CMS, DNV, or state regulatory surveys strongly preferred.
• WORKING CONDITIONS
• Normal office environment with little exposure to excessive noise, dust, temperature and the like.
• PHYSICAL REQUIREMENTS
• Click here to view physical requirements.