Manager, Regulatory and Quality (Clearlake)

Adventist Health•Clearlake, CA

1d•Onsite

About The Position

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
Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP: Required

Responsibilities

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.
Conducts tracers, audits, and readiness rounds; facilitates action plan development with department leaders; and coaches frontline staff to embed compliance and quality standards into everyday practice.
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.
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.
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.
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.
Manages daily operations of quality, patient safety, Regulatory and performance improvement programs.
Supervises and develops Quality/PI, regulatory and patient safety staff, providing mentorship, performance feedback, and coaching.
Ensures alignment of local activities with system strategic priorities.
Leads patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up.
Manages site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings.
Promotes a culture of safety and just culture principles within assigned entity or service line.
Facilitates and oversees improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency.
Applies Lean, Six Sigma, and other performance improvement methodologies and provides coaching to leaders and teams on PI tools and techniques.
Monitors project outcomes and ensures sustainability of improvements.
Ensures timely collection, validation, and reporting of quality, safety, and regulatory metrics.
Prepares and presents data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities.
Partners with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements.
Provides training and mentorship to staff on patient safety, and quality improvement methods.
Fosters interdisciplinary collaboration to improve workflows and outcomes.
Performs other job-related duties as assigned.