Manager of Accreditation - Regulatory and Licensing, Accreditation and Medical Library

ABOUT MARINHEALTH
Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, 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, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch. 

MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others. 

Company:

Marin General Hospital dba MarinHealth Medical Center

Compensation Range:

$72.79 - $109.19

Work Shift:

8 Hour (days) (United States of America)

Scheduled Weekly Hours:

40

Job Description Summary:

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) conditions of participation (COP), California Department of Public Health (CDPH), California Department of Health Care Access and Information (HCAI), California Department of Health Care Services (DHCS), local health authorities, California Children’s Services (CCS), behavioral health licensing requirements, and other applicable accrediting or regulatory bodies. With QMS Executive Director leadership, the Manager translates complex requirements into clear operational expectations; leads enterprise readiness, survey response, corrective action, and licensing activities; identifies and escalates regulatory risk; and partners with executive leadership, medical staff, clinical and operational leaders to sustain compliance, patient safety, and a culture of continuous improvement.

Job Requirements, Prerequisites and Essential Functions:

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.

Prerequisite Skills

• Advanced knowledge of The Joint Commission (TJC) accreditation standards and survey methodology, CMS Conditions of Participation, and California acute-care hospital licensing requirements.
• Demonstrated ability to interpret complex regulatory and accreditation requirements and translate them into practical, measurable operational requirements and corrective actions.
• Working knowledge of regulatory requirements applicable to hospital licensing, specialty accreditation/certification, life safety, environment of care, and healthcare construction, renovation, occupancy, and activation.
• Demonstrated expertise in continuous survey readiness, including tracers, mock surveys, regulatory audits, gap assessments, evidence review, plans of correction, and validation of sustained compliance.
• Strong regulatory risk assessment and problem-solving skills, including data analysis, root-cause analysis, trend identification, performance improvement, and timely escalation of material or recurring risk.
• Demonstrated project and program management skills, including development of work plans, prioritization, assignment of accountability, milestone and deadline management, escalation, and verification of closure.
• Ability to lead complex, multidisciplinary regulatory initiatives and influence executives, physicians, clinical leaders, facilities professionals, and frontline teams without relying solely on positional authority.
• Strong knowledge of policy and procedure governance, including regulatory review, approval processes, implementation, maintenance, and organizational accountability.
• Advanced written, verbal, presentation, facilitation, and consultation skills, with the ability to communicate complex regulatory requirements and organizational risk clearly to audiences ranging from frontline staff to executive leadership and governance bodies.
• Demonstrated ability to develop and communicate regulatory dashboards, readiness metrics, findings, trends, and executive-level reports that support informed decision-making.
• Strong judgment, discretion, organization, and attention to detail, with demonstrated ability to manage multiple high-priority regulatory activities and deadlines in a complex, 24/7 acute-care environment.
• Ability to maintain accurate, organized, audit-ready regulatory records and evidence supporting accreditation, licensing, surveys, corrective actions, and regulatory submissions.
• Demonstrated ability to foster accountability, collaboration, respectful challenge, transparency, and service excellence consistent with MarinHealth C.A.R.E.S. standards.

Primary Customer Served (Age Specific)

• This role is not patient/family facing role
• This role's primary customer are adult staff, managers, physicians and provider leaders

Patient Privacy (HIPAA Compliance):

• This role is not a patient care role
• This role upholds HIPAA compliance when interfacing with regulators and others

Duties And Responsibilities:
Essential Duties (Not Modifiable)
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, and healthcare construction.

Reporting and Governance

• Prepare reports, dashboards, and presentations for Medical Executive Committee, Quality Committee, Environment of Care Committee, Executive Leadership Team, and Governing Board.
• Present regulatory readiness status, survey outcomes, compliance risks, construction-related regulatory updates, and mitigation plans.
• Maintain organizational regulatory documentation and evidence repositories.

Secondary Duties (Modifiable)

• Supports the Risk Manager and Executive Director with timely response to significant and reportable events. 

Accommodation:

Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or [email protected].

C.A.R.E.S. Standards:

MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues.

Health & Immunizations:

To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law.

Compensation:

The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements.

Equal Employment:

All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.