Manager of Accreditation and Regulatory Information, Accreditation and Medical Library, Full-Time, Days

MarinHealth is an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, and a new state-of-the-art hospital, MarinHealth comprises MarinHealth Medical Center (a 327-bed hospital in Greenbrae) and 55 primary care and specialty clinics across Marin, Sonoma, and Napa Counties.

About the role

Manages and collaborates with the Director of Quality Management Services in developing and managing data systems that support ongoing regulatory compliance. Performs analytical and project management work to support the Accreditation program, ensuring compliance with Joint Commission standards and other state and federal regulatory requirements.

Responsibilities

• Works with the Director, Quality Management Services to develop data collection and assessment tools to support compliance activities in response to dynamic regulatory requirements.
• Oversees and leads the Continuous Readiness team; develops and submits the Periodic Performance Review; supports Chapter leaders in implementing new and revised standards.
• Acts as a trusted resource for Federal, State, and local regulatory agencies (e.g., CMS, OSHPD) and accrediting agency requirements to ensure compliance.
• Manages ongoing tracer activities in collaboration with other departments using standardized tools and methodologies.
• Provides timely feedback about findings and staff performance to appropriate managers; synthesizes data into summary formats to facilitate conclusions and recommendations.
• Analyzes and reports findings; uses tracer tools to identify system issues and evaluate corrective actions and improvement strategies.
• Manages and distributes a Joint Commission scorecard across the organization.
• Supports continuous readiness activities, including preparation, organization, and maintenance of documents related to project management, meeting agendas, action plans, and reports.
• Participates in designing and developing Joint Commission-related and other regulatory-driven education curricula, materials, tools, and instructional methodologies.
• Interfaces with executives to develop work plans for and track progress on the Joint Commission Readiness Plan and aspects of operations pertaining to regulatory compliance.
• Serves as liaison to the California Department of Public Health Services for all licensing-related activities, including General Acute Care Hospital surveys and event investigations.
• Supports content experts in ensuring licensure applications and compliance.
• Develops and monitors operational, capital, and staffing budgets.
• Develops and maintains policies and procedures related to accreditation and regulations.
• Works with the Community Relations Department to plan/coordinate promotional materials and events related to accreditation.
• Manages and maintains regulatory status of House-wide Administrative and Clinical policies and procedures; assists with the approval process of departmental policies.
• Manages and maintains regulatory status of hospital forms.
• Performs other duties as assigned.

Requirements

• Bachelor’s degree required.
• Five years of experience in a management or leadership role within a hospital or healthcare organization with responsibility for accreditation and regulations.

Skills

• Knowledge of Joint Commission standards and survey process.
• Excellent analytical, project management, and independent problem-solving skills.
• Ability to review medical records and abstract pertinent clinical and other information using regulatory assessment tools, audits, and monitoring activities.
• Ability to develop appropriate data collection and assessment tools to support compliance activities.
• Proficiency in Word, Excel, and PowerPoint or equivalent software.
• Excellent communication skills (oral, electronic, and written).
• Strong judgment, attention to process and detail.
• Ability to apply discretion, confidentiality, tact, and handle sensitive issues.
• Ability to work independently and interdependently.
• Evidence of continuing professional development.
• Excellent customer service skills.
• Ability to set priorities and manage multiple demands effectively.
• Ability to function autonomously and take initiative.
• Collaborative skills to work with hospital staff, physicians, and outside agencies.
• Ability to manage change through collaborative and positive leadership.
• Ability to communicate effectively with executives, physicians, directors, managers, and staff.
• Excellent organizational skills.
• Ability to interact with all levels of staff and management.

Benefits

• Measles, mumps, varicella, and annual influenza immunizations required (medical or religious exemptions considered).

Pay

Compensation range: $54.32 - $81.48 per hour.

Schedule

• 8-hour day shift.
• 40 scheduled weekly hours.