Manager, Regulatory and Quality (Portland)

About the role

Responsible for the day-to-day coordination, implementation, and monitoring of activities that support continuous accreditation readiness, regulatory compliance, and quality improvement within the hospital. Ensures that operational practices align with the requirements of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other regulatory and accrediting bodies. Executes processes that sustain compliance with corrective action plans, prepare departments for surveys, and drive targeted performance improvement projects.

Responsibilities

• Conducts tracers, audits, and readiness rounds;
• Facilitates action plan development with department leaders;
• Coaches frontline staff to embed compliance and quality standards into everyday practice;
• Maintains and interprets measurement systems, dashboards, and quality indicators to track progress, identify gaps, and escalate risks;
• Reduces patient harm, improves clinical effectiveness, and strengthens performance on external benchmarks such as CMS Star Ratings;
• Supervises, mentors, and develops staff, fostering a culture of accountability and continuous improvement;
• Supports survey logistics, regulatory documentation, and timely reporting, ensuring the organization is consistently prepared for external review and positioned to achieve high-quality, safe, and compliant care delivery.

Requirements

• Education and Work Experience: Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience;
• Required Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement;
• Preferred Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration;
• Licenses/Certifications: Lean or Six Sigma Green Belt or GE Change Management certification.

Qualifications

• Education: Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience;
• Experience: Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement;
• Preferred: Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration;
• Licenses/Certifications: Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP.

Skills

• Lean or Six Sigma Green Belt or GE Change Management certification;
• Leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance;
• Collaboration to improve workflows and outcomes;
• Training and mentorship to staff on patient safety, and quality improvement methods;
• Interpreting and assisting hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations;
• Monitoring project outcomes and ensure sustainability of improvements;
• Timely collection, validation, and reporting of quality, safety, and regulatory metrics;
• Preparing and presenting data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities;
• Partnership with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements.

Benefits

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. Medical and religious exemptions may apply.

Pay

The estimated base pay for this position is $108,913 to $163,369. Additional individual compensation may be available for this role through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information.

Hiring Department

Quality Resources

Locations

Portland, OR, United States

Assignment Category

Full-time regular

Job Shift

Day Shift

Job Info

Job Identification : 63099
Job Category : Manager
Posting Date : 2026-06-12T20:05:41+00:00
Job Shift : Day Shift
Locations : Portland, OR, United States
Assignment Category : Full-time regular
Pay Range : The estimated base pay for this position is $108,913 to $163,369. Additional individual compensation may be available for this role through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information.