Accreditation and Regulatory Analyst (Roseville)

Adventist Health•Roseville, CA

1d•Onsite

About The Position

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.

Requirements

Associate's/Technical Degree or equivalent combination of education/related experience: Required
Two years' experience in healthcare: Required
Lean or Six Sigma Green Belt or GE Change Management certification: Required
Lean or Six Sigma Green Belt (LGB): Required

Nice To Haves

Three years' experience with health care compliance and regulatory activities and two years' experience with project management: Preferred

Responsibilities

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.