Adventist Health

Faith-based nonprofit integrated health system

Accreditation and Regulatory Specialist

Regulatory Compliance & EthicsPosted on Nov 13

Full-timeBakersfield, CA, USA

About the Job

Requirements

An associate's or technical degree, or an equivalent combination of education and related experience, is required.
Two years of healthcare experience are required.
Three years of experience with healthcare compliance and regulatory activities and two years of project management experience are preferred.
A Lean or Six Sigma Green Belt or GE Change Management certification is preferred.

Responsibilities

Support organizational compliance with federal, state, and accrediting-body standards, including The Joint Commission, Centers for Medicare & Medicaid Services, and applicable state departments of health.
Support continuous regulatory readiness through audits, tracer activities, mock surveys, and gap analyses, and coordinate accreditation surveys and regulatory reviews.
Serve as a subject matter resource for assigned departments by interpreting regulatory requirements, supporting policy alignment, and collaborating with operational leaders to ensure compliance with applicable standards.
Support regulatory readiness and compliance activities across assigned hospitals and care settings within the network or market.
Collaborate with clinical and operational leaders across inpatient, outpatient, and support departments to ensure consistent implementation of accreditation and regulatory standards.
Independently conduct regulatory audits and site visits, track compliance trends, support corrective action planning, and assist with regulatory reporting and survey logistics.
Contribute to staff education, data management, and accreditation program administration.
Conduct regulatory audits, tracers, mock surveys, and compliance reviews to evaluate adherence to accreditation and regulatory standards.
Maintain awareness of current and emerging regulatory requirements and prepare departments for surveys conducted by regulatory agencies and accrediting bodies.
Support command center operations during surveys and assist departments in responding to surveyor requests.
Coordinate survey completion and ensure follow-up activities are completed within required timelines.
Conduct routine compliance monitoring, including tracer rounds, focused audits, and mock surveys, to identify regulatory and operational gaps.
Perform gap analyses related to accreditation and regulatory requirements and recommend corrective actions.
Track, trend, and report audit findings and compliance indicators to leadership and operational teams.
Collaborate with departments to develop and implement corrective action plans and monitor progress toward compliance.
Coordinate logistics for regulatory and accrediting-body surveys, including scheduling communications, team assignments, and preparation of materials for surveyors and internal stakeholders.
Support evaluation, planning, and continuous-readiness activities to maintain deemed-status accreditation and compliance with federal, state, and local regulatory requirements and licenses.
Facilitate strategies to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment, including Intracycle Monitoring, tracers, rounds, mock surveys, and gap analyses.
Administer and support tracer management systems, including development of tracers and audits, user assignments, report generation, training, and oversight to ensure adherence to systemwide requirements.
Assist with development and delivery of regulatory education and training for leaders and staff regarding accreditation standards and survey-readiness practices.
Perform other job-related duties as assigned.

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Adventist Health Bakersfield is seeking an Accreditation and Regulatory Specialist for a full-time position with 8-hour day shifts. We are looking for a qualified and dedicated individual who is able to work onsite at our Bakersfield, CA location.

Supports organizational compliance with federal, state, and accrediting body standards including but not limited to The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and applicable State Departments of Health (e.g., California Department of Public Health [CDPH], Oregon Health Authority [OHA], Hawaii Department of Health). Reports to the Director or Manager of Accreditation & Regulatory Compliance and supports continuous regulatory readiness through audits, tracer activities, mock surveys, and gap analyses, while coordinating accreditation surveys and regulatory reviews. Serves as a subject matter resource for assigned departments by interpreting regulatory requirements, supporting policy alignment, and collaborating with operational leaders to ensure compliance with applicable standards. Supports regulatory readiness and compliance activities across assigned hospitals and care settings within the network or market. Collaborates with clinical and operational leaders across inpatient, outpatient, and support departments to ensure consistent implementation of accreditation and regulatory standards. Independently conducts regulatory audits and site visits, tracks compliance trends, supports corrective action planning, and assists with regulatory reporting and survey logistics. The specialist also contributes to staff education, data management, and accreditation program administration to promote a culture of safety, accountability, and sustained regulatory excellence.

Job 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

Licenses/Certifications:

Lean or Six Sigma Green Belt or GE Change Management certification: Preferred

Essential Functions:

Conducts regulatory audits, tracers, mock surveys, and compliance reviews to evaluate adherence to accreditation and regulatory standards. Maintains awareness of current and emerging regulatory requirements and prepare departments for surveys conducted by regulatory agencies and accrediting bodies (e.g., TJC, CMS, and State Departments of Health). Supports command center operations during surveys and assist departments in responding to surveyor requests. Coordinates completion of surveys and ensure follow-up activities are completed within required timelines.
Conducts routine compliance monitoring including tracer rounds, focused audits, and mock surveys to identify regulatory and operational gaps. Performs gap analyses related to accreditation and regulatory requirements and recommend corrective actions. Tracks, trends, and reports audit findings and compliance indicators to leadership and operational teams. Collaborates with departments to develop and implement corrective action plans (CAPs) and monitor progress toward compliance.
Coordinates logistics for regulatory and accrediting body surveys, including scheduling communications, team assignments, and preparation of materials for surveyors and internal stakeholders. Supports the evaluation, planning and continuous readiness activities to maintain deemed status accreditation (e.g. The Joint Commission) and compliance with federal, state, and local regulatory requirements and licenses.
Facilitates strategies to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment, such as Intracycle Monitoring, tracers, rounds, mock surveys and gap analyses.
Administers and supports use of tracer management systems including development of tracers/audits, user assignments, report generation, training and oversight to ensure adherence to systemwide requirements. Assists with development and delivery of regulatory education and training for leaders and staff regarding accreditation standards and survey readiness practices.
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 $81,273 to $121,909. 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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