Manager, Accreditation & Regulatory Compliance

About the role

Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets. Implements system strategies and supports continuous survey readiness through operational execution. Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements.

Responsibilities

• Leads corrective action planning, staff training, and policy implementation at facility level.
• Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission.
• Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction.
• Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues.
• Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing.
• Oversees accreditation and regulatory compliance activities affecting all clinical and non-clinical departments, ensuring regulatory requirements are integrated into operational workflows, policies, and performance improvement initiatives.

Requirements

• Education and Work Experience: Bachelor’s Degree or equivalent combination of education/related experience: Required Master's Degree: Preferred Five years' healthcare or related experience: Preferred Three years' in accreditation, regulatory compliance or process improvements: Preferred Two years' leadership experience: Preferred

Licenses/Certifications

• Healthcare Accreditation Certificated Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification: Required within 2 years of hire date

Essential Functions

• Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals.
• Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care.
• Affords leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance.
• Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations.
• Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system.
• Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance.

Organizational Requirements

• Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable.
• Adventist Health participates in E-Verify. Visit here for more information about E-Verify.

About Us

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.