Manager, Accreditation & Regulatory Compliance (White Memorial)

Adventist Health•Los Angeles, CA

4d•Onsite

About The Position

Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets. Implements system strategies and supports continuous survey readiness through operational execution. Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements. Leads corrective action planning, staff training, and policy implementation at facility level. Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission. Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction. Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues. Manages the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment. Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing. Oversees accreditation and regulatory compliance activities affecting all clinical and non-clinical departments, ensuring regulatory requirements are integrated into operational workflows, policies, and performance improvement initiatives.

Requirements

Bachelor's Degree or equivalent combination of education/related experience: Required
Healthcare Accreditation Certificated Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification: Required within 2 years of hire date

Nice To Haves

Master's Degree: Preferred
Five years' healthcare or related experience: Preferred
Three years' in accreditation, regulatory compliance or process improvements: Preferred
Two years' leadership experience: Preferred

Responsibilities

Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets.
Implements system strategies and supports continuous survey readiness through operational execution.
Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements.
Leads corrective action planning, staff training, and policy implementation at facility level.
Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission.
Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction.
Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues.
Manages the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment.
Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing.
Oversees accreditation and regulatory compliance activities affecting all clinical and non-clinical departments, ensuring regulatory requirements are integrated into operational workflows, policies, and performance improvement initiatives.
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.
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.
Designs and implement systems to ensure a state of continual regulatory, licensure and accreditation compliance.
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.
Maintains and controls all regulatory, licensure and accreditation documents.
Monitors Joint Commission standards compliance.
Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed.
Identifies compliance issues that require follow-up or investigation.
Manages the internal investigations of compliance issues.
Reviews operational risks and develops risk management strategies.
Prepares and submits reports following the review of unusual occurrences and adverse events.
Alerts appropriate regulatory bodies as required in partnership with network director.
Reviews unusual occurrences and adverse events, ensuring that immediate corrective actions are implemented for all reportable events to safeguard patient safety and regulatory compliance.
Maintains accurate documentation and reporting systems to support timely submission of required reports and regulatory filings, in alignment with organizational and regulatory standards.
Participates in root cause analysis, apparent cause analysis as needed.
Collaborates with Risk Management, Quality, Medical staff and other hospital departments as needed in matters related to regulatory compliance, policy planning, and implementation.
Performs other job-related duties as assigned.