Manager, Regulatory and Quality

Adventist Health

1d • Onsite

About The Position

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.

Requirements

• Bachelor’s degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulatory compliance and in quality, patient safety, or performance improvement: Required
• Clinical background: Required
• Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire

Nice To Haves

• 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

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.
• Ensure operational practices align with requirements of CMS, TJC, state agencies, and other regulatory/accrediting bodies.
• Execute processes for sustaining compliance with corrective action plans, preparing departments for surveys, and driving performance improvement projects.
• Conduct tracers, audits, and readiness rounds.
• Facilitate action plan development with department leaders.
• Coach frontline staff to embed compliance and quality standards into everyday practice.
• 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.
• Provide supervision, mentorship, and professional development to assigned staff.
• Support survey logistics, regulatory documentation, and timely reporting.
• 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 for high quality, safe, cost-effective healthcare.
• Assist managers and leaders in mobilizing teams for continuous accreditation standards compliance.
• Coordinate contract renewal and oversight activities for regulatory compliance monitoring systems.
• Provide leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing, and regulatory compliance.
• Manage a team of professionals safeguarding facility licensing status, maintaining accreditations/certifications, and assuring compliance with healthcare regulations.
• Support the accreditation preparation process by managing logistics, conducting mock surveys, and maintaining organizational communication regarding regulatory changes.
• 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 to demonstrate compliance.
• Review, interpret, and assist hospital departments, leadership, and Medical Staff in 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/PI, regulatory, and patient safety staff, providing 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 site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings.
• Promote a culture of safety and just culture principles.
• 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 provide coaching on PI 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 team 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.

Benefits

• All required vaccinations as a condition of employment and annually thereafter, where applicable (Medical and religious exemptions may apply).

What This Job Offers

• Job Type: Full-time
• Career Level: Manager