Adventist Health

Faith-based nonprofit integrated health system

Manager Regulatory and Quality

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours

Full-timeTehachapi, CA, USAIn-person

About the Job

Requirements

A bachelor's degree in nursing, business administration, hospital administration, or an equivalent combination of education and related experience is required.
Three years of experience in accreditation or regulatory compliance and in quality, patient safety, or performance improvement are required.
A clinical background is required.
Lean or Six Sigma Green Belt or GE Change Management certification is required within two years of hire.
All required vaccinations are required as a condition of employment and annually thereafter, where applicable.

Responsibilities

Lead quality improvement and regulatory compliance initiatives across the organization.
Coordinate, implement, and monitor activities supporting continuous accreditation readiness, regulatory compliance, and quality improvement within the hospital.
Ensure operational practices align with Centers for Medicare and Medicaid Services, The Joint Commission, state agency, and other regulatory and accrediting body requirements.
Execute processes that sustain compliance with corrective action plans, prepare departments for surveys, and drive targeted performance improvement projects.
Conduct tracers, audits, and readiness rounds; facilitate action plan development with department leaders; and coach frontline staff on compliance and quality standards.
Maintain and interpret measurement systems, dashboards, and quality indicators to track progress, identify gaps, and escalate risks.
Contribute to initiatives that reduce patient harm, improve clinical effectiveness, and strengthen performance on external benchmarks such as CMS Star Ratings.
Provide supervision, mentorship, and professional development to assigned staff.
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 accreditation standards compliance.
Coordinate contract renewal and oversight activities associated with the regulatory compliance monitoring system.
Provide leadership and expertise in accreditation, licensing, and regulatory compliance.
Manage a team of professionals responsible for facility licensing, accreditations and certifications, and compliance with healthcare regulations.
Support accreditation preparation by managing logistics, conducting mock surveys, and maintaining organizational communication regarding regulatory compliance changes and updates.
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 demonstrating compliance.
Review, interpret, and assist hospital departments, leadership, and medical staff with implementing federal, state, and Joint Commission standards and regulations.
Manage daily operations of quality, patient safety, regulatory, and performance improvement programs.
Supervise and develop quality/performance improvement, regulatory, and patient safety staff through mentorship, performance feedback, and coaching.
Ensure alignment of local activities with system strategic priorities.
Lead patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up.
Manage the site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings.
Promote a culture of safety and just culture principles within the assigned entity or service line.
Facilitate and oversee improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency.
Apply Lean, Six Sigma, and other performance improvement methodologies, and coach leaders and teams on performance improvement tools and techniques.
Monitor project outcomes and ensure sustainability of improvements.
Ensure timely collection, validation, and reporting of quality, safety, and regulatory metrics.
Prepare and present data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities.
Partner with system quality and regulatory teams and patient safety on benchmarking and external reporting requirements.
Provide training and mentorship to staff on patient safety and quality improvement methods.
Foster interdisciplinary collaboration to improve workflows and outcomes.
Perform other job-related duties as assigned.

Desired Qualifications

Five years of experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes.
Two years of leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration.

Adventist Health Tehachapi Valley has been providing high-quality healthcare services since 1934. We are comprised of a 25-bed hospital, wide range of outpatient services, emergency department, rural health clinics and medical offices. Tehachapi is located just north of Southern California's highly populated areas, with a mountain locale known for its outdoor living. Residents enjoy the scenic beauty, extreme sports and wildlife. Tehachapi is a nice balance of a small-town community within an epicenter of shopping, retail, arts and culture.

Job Summary:

Adventist Health Tehachapi Valley is seeking a Manager, Regulatory and Quality for a full-time position working 8-hour day shifts. This role is based onsite in Tehachapi, CA. We are looking for an experienced professional to lead quality improvement and regulatory compliance initiatives across the organization.

Responsible for the day-to-day coordination, implementation, and monitoring of activities that support continuous accreditation readiness, regulatory compliance, and quality improvement within the hospital. Ensures that operational practices align with the requirements of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other regulatory and accrediting bodies. Executes processes that sustain compliance with corrective action plans, prepare departments for surveys, and drive targeted performance improvement projects. This includes conducting tracers, audits, and readiness rounds; facilitating action plan development with department leaders; and coaching frontline staff to embed compliance and quality standards into everyday practice. In partnership with nursing, medical staff, and quality leaders, the Manager maintains and interprets measurement systems, dashboards, and quality indicators to track progress, identify gaps, and escalate risks. Contributes to initiatives that reduce patient harm, improve clinical effectiveness, and strengthen performance on external benchmarks such as CMS Star Ratings. Provides supervision, mentorship, and professional development to assigned staff, fostering a culture of accountability and continuous improvement. Supports survey logistics, regulatory documentation, and timely reporting, ensuring that the organization is consistently prepared for external review and positioned to achieve high-quality, safe, and compliant care delivery.

Job Requirements:

Education and Work Experience:

Bachelor’s degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement: Required
Clinical background: Required
Five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Preferred
Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration: Preferred

Licenses/Certifications:

Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire

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. 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.
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.
Manages daily operations of quality, patient safety, Regulatory and performance improvement programs. Supervises and develops Quality/PI , regulatory and patient safety staff, providing mentorship, performance feedback, and coaching. Ensures alignment of local activities with system strategic priorities.
Leads patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up. Manages site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings. Promoted a culture of safety and just culture principles within assigned entity or service line.
Facilitates and oversee improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency. Applies Lean, Six Sigma, and other performance improvement methodologies methodology and provide coaching to leaders and teams on PI tools and techniques. Monitors project outcomes and ensure sustainability of improvements. Ensures timely collection, validation, and reporting of quality, safety, and regulatory metrics. Prepares and presents data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities. Partners with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements. Provides training and mentorship to staff on patient safety, and quality improvement methods. Fosters interdisciplinary collaboration to improve workflows and outcomes.
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 $108,913 to $163,369. 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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