Regulatory Affairs, Accreditation & Licensing Analyst

About the role

The Regulatory Affairs, Accreditation & Licensing Analyst provides regulatory analysis, compliance evaluation, accreditation readiness, hospital licensing oversight, and document governance support across St. Charles Health System. Serving as a system-wide expert resource, this role interprets federal, state, licensing, and accreditation requirements and analyzes their operational impact across clinical and operational programs.

Responsibilities

• Analyzes and evaluates accreditation, licensing, and regulatory compliance activities to identify risks, compliance gaps, and opportunities for improvement.
• Interprets applicable regulations and accreditation standards and advises leaders on operational impact, regulatory obligations, and survey readiness.
• Conducts enterprise-wide regulatory and accreditation readiness assessments, tracers, audits, and compliance reviews to evaluate adherence to federal, state, and accrediting body requirements and identify opportunities for improvement.
• Analyzes survey findings, corrective actions, compliance metrics, and organizational performance indicators to identify trends, assess regulatory risk, and develop recommendations that support continuous readiness and sustained compliance.
• Captures and coordinates regulatory reporting, Joint Commission submissions, licensure documentation, and survey-related follow-up activities while interpreting regulatory requirements and communicating implications to operational and organizational leaders.
• Promotes and supports the development and ongoing maturation of the organization's regulatory readiness program.
• Interprets and applies Oregon staffing laws and regulations, providing guidance to leaders on operational impact, compliance requirements, and risk mitigation strategies.
• Supports and advises staffing committees, including regulatory requirements, documentation standards, and compliance expectations.
• Evaluates staffing plans, staffing variances, and compliance data to identify trends, risks, and opportunities for improvement.
• Reviews and analyzes staffing complaints from regulatory agencies and manages response development and submission to OHA.
• Tracks, analyzes, and facilitates response to regulatory fines and penalties.
• Provides regulatory oversight for hospital-based licensing activities to ensure ongoing compliance with federal, state, and accrediting agency requirements.
• Coordinates and maintains hospital licenses across all licensed hospital locations while ensuring regulatory requirements are met for existing operations and new service expansions.
• Provides regulatory oversight for hospital-based construction, renovation, and space modification projects in collaboration with Facilities, Planning, Construction and Design, and other system partners.
• Reviews and coordinates licensure applications, inspections, and approvals in accordance with OHA, OSHA, FGI, and CMS requirements.
• Provides enterprise-level oversight and governance of the health system's document management program, ensuring the integrity, accuracy, accessibility, and regulatory compliance of controlled clinical and corporate documents.
• Analyzes and monitors document governance processes, regulatory requirements, and review cycles to ensure policies and organizational documents remain current, compliant, and aligned with accreditation, licensure, and operational standards.
• Serves as the primary resource for document governance matters at the executive level, regularly reporting program performance, compliance status, and governance priorities to senior leadership and organizational committees while facilitating policy review and approval processes.
• Supports regulatory and quality committees, including agenda development, documentation, and follow-up.
• Makes expert recommendations on policy development, revision, and regulatory alignment.
• Supports Lean principles, continuous improvement, and a culture of safety.

Qualifications

• Education: Bachelor’s degree in related field. Preferred: Master’s degree in related field. Formal training in lean, process improvement, accreditation and licensing.
• Licensure/Certification/Registration: Certified Professional in Healthcare Quality within one (1) year. Health Accreditation Certification Program within two (2) years. FEMA Certificates for IS-100, IS-200, IS-700, IS-800 courses within two (2) years. Valid Oregon driver’s license and ability to meet St. Charles Health System driving requirements.
• Experience: Minimum five (5) years’ experience in healthcare accreditation, regulatory compliance, quality, or related healthcare operations. Experience in interpreting regulatory standards and supporting survey readiness activities. Preferred: Clinical and/or advanced experience with Joint Commission, CMS Conditions of Participation, OHA and OSHA. Experience mentoring accreditation and regulatory professionals.

Skills

• Strong understanding of federal, state, and accrediting body regulations.
• Excellent analytical and problem-solving skills.
• Effective communication and interpersonal skills.
• Ability to work independently and as part of a team.
• Proficient in Microsoft Office Suite.

Benefits

St. Charles Health System offers competitive benefits including medical, dental, vision, retirement plans, paid time off, and more.

Pay

Competitive salary based on experience and qualifications.

Schedule

Full-time position with flexible hours to accommodate the needs of the organization.