System Accreditation and Regulatory Specialist (Roseville)

About the role

Supports the work of the Accreditation, Regulatory and Licensing Program at the system level. Supports systemwide regulatory compliance, accreditation readiness, and continuous survey preparedness across Adventist Health hospitals and outpatient services.

Responsibilities

• Conducts regulatory compliance reviews and audits for hospitals, Rural Health Clinics (RHC) and outpatient clinics in collaboration with system AR&L and Ambulatory leadership.
• Supports systemwide chart audits and virtual chart reviews focused on: High-risk regulatory issues, Identified survey trends, other identified regulatory non-compliance.
• Tracks, reviews and provide feedback on mock survey action plans and corrective action strategies.
• Supports CMS plan of correction review process, including: Initial review of action plans, Coordination with System Director for final review and approval.
• Participates as needed and support system and site-level mock surveys for designated hospitals and ambulatory locations.
• Provides chart audit support during mock surveys.
• Affords education and consultation to hospital and clinic teams based on chart audit findings, tracer results, and survey trends.
• Supports regulatory readiness by educating leaders and staff on: CMS Conditions of Participation, Joint Commission standards, State licensing requirements and other applicable regulations.
• Assists with orientation to regulatory database such as RLDatix for new leaders and promote effective use of the platform to support survey readiness.
• Serves as a Regulatory readiness platform (such as RLDatix) subject matter expert, supporting systemwide adoption and effective utilization for survey readiness.
• Assists markets with: Tracer documentation, action plan tracking, survey readiness documentation management.
• Collaborates with system clinical and operational teams to develop, review, and maintain systemwide policies and procedures that support regulatory compliance and best practices.
• Supports regulatory integration into system governance structures and improvement initiatives.
• Assists with development and maintenance of survey readiness tools.
• Provides support for system regulatory initiatives and strategic compliance projects.
• Participates in special projects and regulatory initiatives as assigned by the System Director.
• Travel required to support site visits, mock surveys, and regulatory readiness activities across Adventist Health markets.

Requirements

• Education and Work Experience: Associate’s/Technical Degree or equivalent combination of education/related experience: Required Two years' experience in healthcare: Required Three years' experience with health care compliance and regulatory activities and two years' experience with project management: Preferred

Qualifications

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.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

Benefits

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.

Pay

The estimated base pay for this position is $81,273 to $121,909.

Schedule

Shift Length: 8 Hours