Adventist Health

Faith-based nonprofit integrated health system

Manager – Accreditation & Regulatory Compliance

Regulatory Compliance & EthicsConfirmed live in the last 24 hours

Full-timeUkiah, CA, USAIn-person

About the Job

Requirements

A bachelor's degree or an equivalent combination of education and related experience is required.
Five years of healthcare or related experience is preferred.
Three years of experience in accreditation, regulatory compliance, or process improvements is preferred.
Two years of leadership experience is preferred.
Healthcare Accreditation Certified Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification is required within two years of hire.

Responsibilities

Direct day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals or markets.
Implement system strategies and support continuous survey readiness through operational execution.
Lead site and network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services, The Joint Commission, and state requirements.
Lead corrective action planning, staff training, and policy implementation at facility level.
Manage surveys and regulatory compliance with governmental agencies, including The Joint Commission.
Manage improvement processes and programs related to accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction.
Work with nursing, medical staff, and other disciplines to provide focus and education on accreditation, regulatory, and licensing issues.
Manage activities of assigned personnel using professional and supervisory discretion and independent judgment.
Maintain a dotted-line reporting structure to the system director of accreditation, regulatory, and licensing.
Oversee accreditation and regulatory compliance activities across clinical and non-clinical departments, integrating regulatory requirements into operational workflows, policies, and performance improvement initiatives.
Partner with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals.
Partner with clinical and non-clinical staff to develop, implement, monitor, and improve structures required to achieve high-quality, safe, cost-effective healthcare.
Assist managers and leaders in mobilizing teams throughout the organization to ensure continuous compliance with accreditation standards.
Coordinate contract renewal and oversight activities for regulatory compliance monitoring systems.
Provide leadership and expertise in achieving organizational goals related to accreditation, licensing, and regulatory compliance.
Manage a team of professionals who safeguard facility licensing status, maintain accreditations and certifications, and ensure compliance with healthcare regulations.
Conduct annual state regulatory compliance assessments; develop and maintain action plans and responses to citations from regulatory agencies.
Collect data, prepare graphic presentations, and compile reports to demonstrate compliance.
Review, interpret, and assist hospital departments, leadership, and Medical Staff in implementing federal, state, and Joint Commission standards and regulations.
Design and implement systems that ensure ongoing regulatory, licensure, and accreditation compliance.
Support accreditation preparation by managing logistics, conducting mock surveys, and communicating regulatory compliance changes and updates.
Maintain and control regulatory, licensure, and accreditation documents.
Monitor compliance with Joint Commission standards and conduct periodic internal reviews or audits to ensure compliance procedures are followed.
Identify compliance issues requiring follow-up or investigation and manage internal investigations of compliance issues.
Review operational risks and develop risk management strategies.
Prepare and submit reports after reviewing unusual occurrences and adverse events.
Alert appropriate regulatory bodies as required, in partnership with the network director.
Review unusual occurrences and adverse events and ensure immediate corrective actions are implemented for reportable events to safeguard patient safety and regulatory compliance.
Maintain accurate documentation and reporting systems for timely submission of required reports and regulatory filings in line with organizational and regulatory standards.
Participate in root cause analysis and apparent cause analysis as needed.
Collaborate with Risk Management, Quality, Medical Staff, and other hospital departments on regulatory compliance, policy planning, and implementation.
Perform other job-related duties as assigned.

Desired Qualifications

A master's degree is preferred.

Adventist Health Ukiah Valley has been deeply connected to the community we serve since 1956. We are comprised of a 50-bed acute care medical center, level IV trauma center, level II intensive care nursery services, extensive physical rehabilitation program, outpatient surgery and diagnostic center and advanced wound care center. Ukiah is a unique small town that charms you with its rich character, arts, vineyards and natural surroundings. Ukiah beckons you to explore all that the valley has to offer amidst our 300 days of sunshine each year. We are also conveniently located just two hours north of San Francisco and 45 minutes from the Pacific Coast.

Job Summary:

Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets. Implements system strategies and supports continuous survey readiness through operational execution. Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements. Leads corrective action planning, staff training, and policy implementation at facility level. Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission. Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction. Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues. Manages the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment. Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing. Oversees accreditation and regulatory compliance activities affecting all clinical and non-clinical departments, ensuring regulatory requirements are integrated into operational workflows, policies, and performance improvement initiatives.

Job Requirements:

Education and Work Experience:

Bachelor's Degree or equivalent combination of education/related experience: Required
Master's Degree: Preferred
Five years' healthcare or related experience: Preferred
Three years' in accreditation, regulatory compliance or process improvements: Preferred
Two years' leadership experience: Preferred

Licenses/Certifications:

Healthcare Accreditation Certificated Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification: Required within 2 years of hire date

Essential Functions:

Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals. Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system.
Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations.
Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations.
Designs and implement systems to ensure a state of continual regulatory, licensure and accreditation compliance. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization's communication regarding changes and updates for regulatory compliance. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues. Reviews operational risks and develops risk management strategies
Prepares and submits reports following the review of unusual occurrences and adverse events. Alerts appropriate regulatory bodies as required in partnership with network director. Reviews unusual occurrences and adverse events, ensuring that immediate corrective actions are implemented for all reportable events to safeguard patient safety and regulatory compliance. Maintains accurate documentation and reporting systems to support timely submission of required reports and regulatory filings, in alignment with organizational and regulatory standards. Participates in root cause analysis, apparent cause analysis as needed. Collaborates with Risk Management, Quality, Medical staff and other hospital departments as needed in matters related to regulatory compliance, policy planning, and implementation.
Performs other job-related duties as assigned.

Organizational Requirements:

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.

Pay Range: The estimated base pay for this position is $120,077 to $180,115. 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.

About the Company

Adventist Health

Faith-based nonprofit integrated health system

Adventist Health is a faith-based nonprofit health system with more than 400 sites of care, including 26 acute care hospitals, primarily on the West Coast and in Hawaii. It provides a full range of health services—from primary and specialty care to hospital-based treatments and wellness programs—delivered across an integrated network of clinics, hospitals, and care facilities. Revenue comes from patient services, insurance reimbursements, and government programs, and earnings are reinvested back into communities to improve health outcomes and expand access to care. The organization differentiates itself through its nonprofit, faith-based model and by reinvesting earnings into community health, along with its broad, integrated network that covers preventive, primary, specialty, and acute care. Its goal is to improve health outcomes for the communities it serves and to expand access to high-quality care.

Company size: 10,001+
Company stage: Grant
Total funding: $210K
Headquarters: Roseville, CA
Founded: Not listed

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