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 helps ensure the organization meets or exceeds requirements established by federal and state regulatory bodies, national accrediting organizations, and internal policies, supporting compliance and 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 improve compliance systems. The role facilitates quality improvement projects, including defining scope, developing and monitoring timelines, and documenting outcomes. It manages small, short-duration projects from concept through implementation, supports communication strategies for projects, contributes to staffing more complex projects, and prepares internal and external reports by gathering, analyzing, and summarizing information for management. The position also manages and archives project documents for the Quality team and provides cross-coverage as needed. The successful candidate is an experienced acute-care healthcare professional who works collaboratively with leaders and clinical teams to promote ongoing survey readiness and regulatory compliance. The specialist makes complex requirements understandable and actionable, works across departments to identify opportunities and develop solutions, provides education, and prepares for regulatory surveys and site visits. The position supports enterprise-wide initiatives and the work of leadership, departments, clinics, physicians, and administration. The 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.
Ability and 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 established by 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 quality improvement projects, including scope definition, timeline development and monitoring, and documentation of outcomes.
Manage small, short-duration projects from concept through implementation and assist in developing related communication strategies.
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 the activities of leadership, departments, clinics, physicians, and administration.
Provide cross-coverage for the quality team as necessary.
Provide education and help teams prepare for regulatory surveys and site visits.