Accreditation & Regulatory Specialist

City of Hope•Goodyear, AZ

About The Position

The Accreditation & Regulatory Specialist leads the strategic development, coordination, and execution of regulatory compliance and accreditation activities across City of Hope. The role ensures the organization meets or exceeds requirements established by federal and state regulatory bodies, national accrediting organizations, and internal policies to maintain compliance and support high-quality patient care. The specialist partners with clinical, administrative, legal, and quality teams to interpret changing regulations, guide readiness for surveys and inspections, and drive continuous improvement in compliance systems. The position facilitates performance and quality improvement projects, including defining scope, developing and monitoring timelines, and documenting outcomes to support accreditation and quality standards. It manages short-duration projects from concept through implementation, helps develop related communications such as memos, newsletter articles, and intranet content, and participates in staffing more complex projects. The specialist prepares internal and external project reports by gathering, analyzing, and summarizing information for management, and manages and archives project-related documents for the Quality team. The role also supports enterprise-wide initiatives, leadership team activities, departments, clinics, physicians, and administration, and provides cross-coverage for the quality team as needed. The ideal candidate is an experienced acute-care healthcare professional who works collaboratively with leaders and clinical teams to promote continuous survey readiness and regulatory compliance. They can translate complex TJC, CMS, and other regulatory requirements into actionable guidance, and are organized, approachable, inquisitive, and comfortable working across departments to identify opportunities, develop solutions, provide education, and prepare for surveys and site visits. The position’s stated schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m.

Requirements

A degree in Healthcare Administration, Healthcare, Public Health, Compliance, or Nursing.
Experience in clinical nursing and/or quality, risk, and regulatory activities.
At least five years of acute-care hospital experience.
Strong knowledge of hospital operations and patient care.
Experience participating in or preparing for regulatory surveys.
BLS training.
Willingness to continually learn and apply evolving accreditation and regulatory requirements.

Responsibilities

Lead the strategic development, coordination, and execution of regulatory compliance and accreditation activities across the organization.
Help ensure compliance with requirements from federal and state regulatory bodies, national accrediting organizations, and internal policies.
Partner with clinical, administrative, legal, and quality teams to interpret changing regulations and guide readiness for surveys and inspections.
Drive continuous improvement in compliance systems.
Facilitate performance and quality improvement projects, including scope definition, timeline development and monitoring, and outcome documentation.
Manage short-duration projects from concept through implementation and assist in developing project communications, including memos, newsletter articles, and intranet frameworks and content.
Participate in staffing more complex projects.
Prepare internal and external project reports by gathering, analyzing, and summarizing data and information for management.
Manage and archive project-related documents for the Quality team.
Support enterprise-wide initiatives and activities of the leadership team, departments, clinics, physicians, and administration.
Provide cross-coverage for the quality team as needed.
Provide education and help teams prepare for regulatory surveys and site visits.