Manager of Accreditation, Regulatory and Licensing, Accreditation and Medical Library, Full-Time, Days
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). Use - for any list of duties/requirements/benefits, and
for prose. Do NOT repeat the job title as a heading. Do NOT put Job ID / requisition numbers as headings — fold minor metadata into a short
or drop it. Preserve ALL substantive information; do NOT invent or summarize away detail. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. IMPORTANT: include a section ONLY when the posting has real, specific content for it — never emit a heading followed by filler/placeholder text (e.g. "commensurate with experience", "not specified", "N/A", "varies", "TBD") and never create Pay/Schedule/Benefits sections unless the posting actually states them. Prefer a few substantive sections over many thin ones.
We have content: About MarinHealth (company description). Compensation Range $72.79 - $109.19. Work Shift 8 Hour (days). Scheduled Weekly Hours 40. That's pay and schedule info. So we should include Pay and Schedule sections (since they are stated). Benefits not mentioned. So we can omit Benefits.
We have Job Description Summary (prose). Then Job Requirements, Prerequisites And Essential Functions (includes Education, Experience, Licenses & Certifications, Prerequisite Skills). Also Primary Customer Served, Patient Privacy (HIPAA Compliance). Then Duties And Responsibilities (with subheadings: Accreditation Management, Regulatory Compliance, Licensing Oversight, Survey Readiness and Performance Improvement, Policy & Procedure Coordination, Education and Consultation). Those are duties.
We need to map to sections: About the role (maybe company overview). Responsibilities (duties). Requirements (education, experience, licenses). Qualifications? Could combine with Requirements. Skills (prerequisite skills). Pay (compensation range). Schedule (work shift, weekly hours). We should not create sections with filler.
We need to output only HTML fragment, no /. Use
for each section heading. Use
for prose. Use
- for lists.
We must preserve all substantive information. Not invent or summarize away detail. So we need to include details like accreditation bodies list, etc.
We need to decide how to structure: maybe sections: About the role (company description). Responsibilities (list of duties). Requirements (education, experience, licenses). Skills (prerequisite skills). Pay (compensation range). Schedule (work shift and weekly hours). Possibly also a section for Primary Customer Served and HIPAA? Could be part of About the role or Responsibilities? Might be better to include as a short paragraph under About the role or separate? The instruction: include a section ONLY when posting has real, specific content for it. Primary Customer Served and Patient Privacy are specific content. Could be a section like "Role Focus" but not in the given list. The list of allowed headings is examples, not exclusive? It says use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It suggests those are typical but not strictly limited? It says "use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." Likely they expect those headings. So we should map content to those headings. Primary Customer Served and HIPAA could go under About the role or Responsibilities? Probably under About the role (description of role). We'll incorporate them in prose.
We must not repeat job title as heading. No Job ID.
We must remove boilerplate like EEO etc. Not present.
Now craft HTML.
We'll start with About the role
then
containing MarinHealth description and role summary, plus primary customer served and HIPAA compliance.
Then
Responsibilities
then with each duty as - . Need to include all duties from Duties And Responsibilities subheadings. We'll list each bullet as a duty.
We have many duties: Accreditation Management (list of subitems), Regulatory Compliance (list), Licensing Oversight (list), Survey Readiness and Performance Improvement (list), Policy & Procedure Coordination (list), Education and Consultation (list). We'll combine them into a single list? Could break into subheadings but we only have
for sections; we could use but not allowed? Not specified. Safer to just list all duties as
- items, preserving detail.
We need to ensure we don't lose any detail. Let's extract duties:
Accreditation Management:
- Lead medical center accreditation activities, including The Joint Commission surveys, CMS validation surveys, and other accrediting body reviews.
- Provide accreditation consultation to specialty accreditation teams such as Trauma, Cancer Institute, TJC Disease certifications for Stroke and Diabetes, CA Children’s Services (CCS), etc.
- Develop and maintain a comprehensive accreditation readiness program that supports continuous survey preparedness.
- Monitor and communicate accreditation standards and regulatory changes to hospital leadership and operational teams and consult on plans to meet new standards and regulations.
- Coordinate document reviews, tracer activities, mock surveys, gap assessments, corrective action plans, and evidence collection.
- Prepare executive leadership and staff for announced and unannounced surveys.
Regulatory Compliance:
- Manage regulatory compliance activities related to federal, state, and local healthcare regulations.
- Monitor changes to healthcare laws, regulations, and regulatory guidance affecting hospital operations.
- Conduct compliance assessments and audits to identify risks and opportunities for improvement.
- Coordinate responses to regulatory findings, deficiencies, plans of correction, and corrective action monitoring.
- Collaborate with legal, compliance, and quality departments to mitigate regulatory risk.
- Participate in Emergency Management preparedness efforts and coordinate with Environment of Care initiatives for general safety.
- Partner with Specialty Program leaders (i.e. Trauma Program, Behavioral Health, Maternal Child/NICU) to ensure compliance with state regulations and verification standards.
Licensing Oversight:
- Lead and manage hospital licensing activities with California Department of Public Health and other applicable licensing agencies.
- Coordinate applications, renewals, modifications, and changes of service related to: General Acute Care Hospital licensure, Level III Trauma Center designation, Level II Neonatal Intensive Care Unit (NICU), Acute Behavioral Health/Psychiatric Services licensure and certification, Specialty service approvals and program certifications.
- Ensure timely submission of required reports, data, and documentation to licensing agencies.
- Maintain regulatory documentation supporting licensed bed capacity, service changes, space modifications, and facility expansions.
- Provide consultation to leaders for operational readiness and compliance with Federal and State regulations for new and expanded services.
- Collaborate with Facilities Management, Design and Construction, Safety, Infection Prevention, Security, Emergency Management, and operational leaders to support regulatory compliance associated with hospital construction, renovation, infrastructure modernization, and department relocations.
- Monitor construction-related regulatory requirements to ensure ongoing compliance during active healthcare construction projects and phased occupancies.
- Serve as a subject matter expert regarding the impact of construction activities on licensure, accreditation, patient safety, and regulatory compliance.
Survey Readiness and Performance Improvement:
- Develop and implement an organization-wide continuous readiness framework.
- Conduct routine tracers, environmental rounds, documentation reviews, and readiness assessments.
- Facilitate multidisciplinary teams to address identified compliance gaps.
- Track and trend compliance metrics and present findings to leadership committees.
- Promote regulatory compliance through performance improvement methodologies.
- Lead mock surveys and readiness assessments focused on accreditation, licensing, life safety, and construction-related compliance.
Policy & Procedure Coordination:
- Develop and implement organization-wide framework and tools for sustaining policies/procedures guiding clinical care and administrative excellence.
- Provide consultation and education to leaders, physicians, and staff regarding policy procedures and clinical protocols development and implementation process.
- Chairs the medical center policy and procedure committee.
- Reviews medical center wide policies to ensure cross functional impacts and compliance with regulations have been robustly considered and addressed.
- Ensures consistency of P&P development to sustain regulatory readiness.
Education and Consultation:
- Provide consultation and education to leaders, physicians, and staff regarding accreditation, licensing, construction-related regulatory requirements, and compliance expectations.
- Develop training materials and regulatory updates for leadership and frontline teams.
- Serve as the organization’s primary internal resource for accreditation and regulatory interpretation.
- Educate leaders regarding new and emerging regulatory requirements affecting acute care, trauma, NICU, behavioral health, life safety,
(Note: the last bullet seems truncated; we should keep as is.)
Now Requirements section: includes Education, Experience, Licenses & Certifications, Prerequisite Skills? Actually Prerequisite Skills is separate. We'll separate Requirements (education, experience, licenses) and Skills (prerequisite skills). Also Qualifications maybe same as Requirements; but we can just have Requirements and Skills.
Education: Bachelor’s degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or a related field required. Master’s degree in nursing, Healthcare Administration, Public Health, Business Administration, or a related healthcare field preferred.
Experience: Five (5) to seven (7) years of progressively responsible experience in healthcare accreditation, regulatory compliance, quality management, licensing, patient safety, or a related healthcare operational function required. Experience supporting or leading TJC, CMS, CDPH, or other regulatory surveys/inspections in an acute care hospital required. Demonstrated experience leading regulatory readiness, gap assessment, corrective action, and complex cross-functional projects required. Clinical experience in a California acute care hospital preferred. Experience with trauma, NICU, behavioral health, specialty certification, plans of correction, regulatory agency interaction, and/or healthcare construction/activation preferred. Leadership or program-management experience with demonstrated ability to influence outcomes across functions preferred.
Licenses & Certifications: California Registered Nurse license preferred when relevant to the candidate’s clinical background. CPHQ, CJCP, CPPS, Lean Six Sigma, Healthcare Construction Certificate (HCC), or comparable accreditation/quality/regulatory credential preferred. For candidates without a relevant professional certification, willingness to obtain an agreed-upon accreditation, quality, patient safety, or regulatory credential within two (2) years of hire is preferred.
Now Skills (Prerequisite Skills): list each bullet.
We'll list them as
- .
Pay: Compensation Range $72.79 - $109.19.
Schedule: Work Shift 8 Hour (days). Scheduled Weekly Hours 40.
We'll put Pay and Schedule sections.
Now ensure we don't include filler like "commensurate with experience". Not present.
Now produce HTML.
We'll start:
About the role
MarinHealth is an integrated, independent healthcare system with deep roots throughout the North Bay, featuring a world-class physician and clinical team, an affiliation with UCSF Health, an expanding network of clinics, and a new state-of-the-art hospital. MarinHealth Medical Center is a 327-bed hospital in Greenbrae with 55 primary care and specialty clinics across Marin, Sonoma, and Napa Counties. The organization attracts talented professionals seeking the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch, and has earned accolades including being named one of the Top 250 Hospitals Nationwide by Healthgrades, a 5-star Ranking for Overall Hospital Quality from CMS, and Best Hospital in San Francisco/Marin by Bay Area Parent. The Accreditation, Regulatory & Licensing Manager provides strategic leadership and operational management for continuous accreditation, regulatory, and clinical licensing readiness across MarinHealth Medical Center. The role serves as an organizational subject matter expert for The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS
for prose. Do NOT repeat the job title as a heading. Do NOT put Job ID / requisition numbers as headings — fold minor metadata into a short
or drop it. Preserve ALL substantive information; do NOT invent or summarize away detail. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. IMPORTANT: include a section ONLY when the posting has real, specific content for it — never emit a heading followed by filler/placeholder text (e.g. "commensurate with experience", "not specified", "N/A", "varies", "TBD") and never create Pay/Schedule/Benefits sections unless the posting actually states them. Prefer a few substantive sections over many thin ones. We have content: About MarinHealth (company description). Compensation Range $72.79 - $109.19. Work Shift 8 Hour (days). Scheduled Weekly Hours 40. That's pay and schedule info. So we should include Pay and Schedule sections (since they are stated). Benefits not mentioned. So we can omit Benefits. We have Job Description Summary (prose). Then Job Requirements, Prerequisites And Essential Functions (includes Education, Experience, Licenses & Certifications, Prerequisite Skills). Also Primary Customer Served, Patient Privacy (HIPAA Compliance). Then Duties And Responsibilities (with subheadings: Accreditation Management, Regulatory Compliance, Licensing Oversight, Survey Readiness and Performance Improvement, Policy & Procedure Coordination, Education and Consultation). Those are duties. We need to map to sections: About the role (maybe company overview). Responsibilities (duties). Requirements (education, experience, licenses). Qualifications? Could combine with Requirements. Skills (prerequisite skills). Pay (compensation range). Schedule (work shift, weekly hours). We should not create sections with filler. We need to output only HTML fragment, no /. Use
for each section heading. Use
for prose. Use
- for lists.
We must preserve all substantive information. Not invent or summarize away detail. So we need to include details like accreditation bodies list, etc.
We need to decide how to structure: maybe sections: About the role (company description). Responsibilities (list of duties). Requirements (education, experience, licenses). Skills (prerequisite skills). Pay (compensation range). Schedule (work shift and weekly hours). Possibly also a section for Primary Customer Served and HIPAA? Could be part of About the role or Responsibilities? Might be better to include as a short paragraph under About the role or separate? The instruction: include a section ONLY when posting has real, specific content for it. Primary Customer Served and Patient Privacy are specific content. Could be a section like "Role Focus" but not in the given list. The list of allowed headings is examples, not exclusive? It says use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It suggests those are typical but not strictly limited? It says "use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." Likely they expect those headings. So we should map content to those headings. Primary Customer Served and HIPAA could go under About the role or Responsibilities? Probably under About the role (description of role). We'll incorporate them in prose. We must not repeat job title as heading. No Job ID. We must remove boilerplate like EEO etc. Not present. Now craft HTML. We'll start with
About the role
thencontaining MarinHealth description and role summary, plus primary customer served and HIPAA compliance. Then
Responsibilities
then- with each duty as
- . Need to include all duties from Duties And Responsibilities subheadings. We'll list each bullet as a duty.
We have many duties: Accreditation Management (list of subitems), Regulatory Compliance (list), Licensing Oversight (list), Survey Readiness and Performance Improvement (list), Policy & Procedure Coordination (list), Education and Consultation (list). We'll combine them into a single list? Could break into subheadings but we only have
for sections; we could use
but not allowed? Not specified. Safer to just list all duties as
- items, preserving detail.
We need to ensure we don't lose any detail. Let's extract duties:
Accreditation Management:
- Lead medical center accreditation activities, including The Joint Commission surveys, CMS validation surveys, and other accrediting body reviews.
- Provide accreditation consultation to specialty accreditation teams such as Trauma, Cancer Institute, TJC Disease certifications for Stroke and Diabetes, CA Children’s Services (CCS), etc.
- Develop and maintain a comprehensive accreditation readiness program that supports continuous survey preparedness.
- Monitor and communicate accreditation standards and regulatory changes to hospital leadership and operational teams and consult on plans to meet new standards and regulations.
- Coordinate document reviews, tracer activities, mock surveys, gap assessments, corrective action plans, and evidence collection.
- Prepare executive leadership and staff for announced and unannounced surveys.
Regulatory Compliance:
- Manage regulatory compliance activities related to federal, state, and local healthcare regulations.
- Monitor changes to healthcare laws, regulations, and regulatory guidance affecting hospital operations.
- Conduct compliance assessments and audits to identify risks and opportunities for improvement.
- Coordinate responses to regulatory findings, deficiencies, plans of correction, and corrective action monitoring.
- Collaborate with legal, compliance, and quality departments to mitigate regulatory risk.
- Participate in Emergency Management preparedness efforts and coordinate with Environment of Care initiatives for general safety.
- Partner with Specialty Program leaders (i.e. Trauma Program, Behavioral Health, Maternal Child/NICU) to ensure compliance with state regulations and verification standards.
Licensing Oversight:
- Lead and manage hospital licensing activities with California Department of Public Health and other applicable licensing agencies.
- Coordinate applications, renewals, modifications, and changes of service related to: General Acute Care Hospital licensure, Level III Trauma Center designation, Level II Neonatal Intensive Care Unit (NICU), Acute Behavioral Health/Psychiatric Services licensure and certification, Specialty service approvals and program certifications.
- Ensure timely submission of required reports, data, and documentation to licensing agencies.
- Maintain regulatory documentation supporting licensed bed capacity, service changes, space modifications, and facility expansions.
- Provide consultation to leaders for operational readiness and compliance with Federal and State regulations for new and expanded services.
- Collaborate with Facilities Management, Design and Construction, Safety, Infection Prevention, Security, Emergency Management, and operational leaders to support regulatory compliance associated with hospital construction, renovation, infrastructure modernization, and department relocations.
- Monitor construction-related regulatory requirements to ensure ongoing compliance during active healthcare construction projects and phased occupancies.
- Serve as a subject matter expert regarding the impact of construction activities on licensure, accreditation, patient safety, and regulatory compliance.
Survey Readiness and Performance Improvement:
- Develop and implement an organization-wide continuous readiness framework.
- Conduct routine tracers, environmental rounds, documentation reviews, and readiness assessments.
- Facilitate multidisciplinary teams to address identified compliance gaps.
- Track and trend compliance metrics and present findings to leadership committees.
- Promote regulatory compliance through performance improvement methodologies.
- Lead mock surveys and readiness assessments focused on accreditation, licensing, life safety, and construction-related compliance.
Policy & Procedure Coordination:
- Develop and implement organization-wide framework and tools for sustaining policies/procedures guiding clinical care and administrative excellence.
- Provide consultation and education to leaders, physicians, and staff regarding policy procedures and clinical protocols development and implementation process.
- Chairs the medical center policy and procedure committee.
- Reviews medical center wide policies to ensure cross functional impacts and compliance with regulations have been robustly considered and addressed.
- Ensures consistency of P&P development to sustain regulatory readiness.
Education and Consultation:
- Provide consultation and education to leaders, physicians, and staff regarding accreditation, licensing, construction-related regulatory requirements, and compliance expectations.
- Develop training materials and regulatory updates for leadership and frontline teams.
- Serve as the organization’s primary internal resource for accreditation and regulatory interpretation.
- Educate leaders regarding new and emerging regulatory requirements affecting acute care, trauma, NICU, behavioral health, life safety,
(Note: the last bullet seems truncated; we should keep as is.)
Now Requirements section: includes Education, Experience, Licenses & Certifications, Prerequisite Skills? Actually Prerequisite Skills is separate. We'll separate Requirements (education, experience, licenses) and Skills (prerequisite skills). Also Qualifications maybe same as Requirements; but we can just have Requirements and Skills.
Education: Bachelor’s degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or a related field required. Master’s degree in nursing, Healthcare Administration, Public Health, Business Administration, or a related healthcare field preferred.
Experience: Five (5) to seven (7) years of progressively responsible experience in healthcare accreditation, regulatory compliance, quality management, licensing, patient safety, or a related healthcare operational function required. Experience supporting or leading TJC, CMS, CDPH, or other regulatory surveys/inspections in an acute care hospital required. Demonstrated experience leading regulatory readiness, gap assessment, corrective action, and complex cross-functional projects required. Clinical experience in a California acute care hospital preferred. Experience with trauma, NICU, behavioral health, specialty certification, plans of correction, regulatory agency interaction, and/or healthcare construction/activation preferred. Leadership or program-management experience with demonstrated ability to influence outcomes across functions preferred.
Licenses & Certifications: California Registered Nurse license preferred when relevant to the candidate’s clinical background. CPHQ, CJCP, CPPS, Lean Six Sigma, Healthcare Construction Certificate (HCC), or comparable accreditation/quality/regulatory credential preferred. For candidates without a relevant professional certification, willingness to obtain an agreed-upon accreditation, quality, patient safety, or regulatory credential within two (2) years of hire is preferred.
Now Skills (Prerequisite Skills): list each bullet.
We'll list them as
- .
Pay: Compensation Range $72.79 - $109.19.
Schedule: Work Shift 8 Hour (days). Scheduled Weekly Hours 40.
We'll put Pay and Schedule sections.
Now ensure we don't include filler like "commensurate with experience". Not present.
Now produce HTML.
We'll start:
About the role
MarinHealth is an integrated, independent healthcare system with deep roots throughout the North Bay, featuring a world-class physician and clinical team, an affiliation with UCSF Health, an expanding network of clinics, and a new state-of-the-art hospital. MarinHealth Medical Center is a 327-bed hospital in Greenbrae with 55 primary care and specialty clinics across Marin, Sonoma, and Napa Counties. The organization attracts talented professionals seeking the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch, and has earned accolades including being named one of the Top 250 Hospitals Nationwide by Healthgrades, a 5-star Ranking for Overall Hospital Quality from CMS, and Best Hospital in San Francisco/Marin by Bay Area Parent. The Accreditation, Regulatory & Licensing Manager provides strategic leadership and operational management for continuous accreditation, regulatory, and clinical licensing readiness across MarinHealth Medical Center. The role serves as an organizational subject matter expert for The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS
- .
Pay: Compensation Range $72.79 - $109.19.
Schedule: Work Shift 8 Hour (days). Scheduled Weekly Hours 40.
We'll put Pay and Schedule sections.
Now ensure we don't include filler like "commensurate with experience". Not present.
Now produce HTML.
We'll start:
- . Need to include all duties from Duties And Responsibilities subheadings. We'll list each bullet as a duty.
We have many duties: Accreditation Management (list of subitems), Regulatory Compliance (list), Licensing Oversight (list), Survey Readiness and Performance Improvement (list), Policy & Procedure Coordination (list), Education and Consultation (list). We'll combine them into a single list? Could break into subheadings but we only have