Program Manager, Accreditation and Regulatory Compliance

Adventist Health

About The Position

The Program Manager leads Adventist Health’s site accreditation and regulatory compliance program, ensuring alignment with applicable laws, government regulations, and federal, state, and accrediting-body standards, including Centers for Medicare & Medicaid Services and The Joint Commission requirements. The role provides oversight of regulatory risk and survey-readiness strategy in alignment with system priorities, and designs, implements, and optimizes programs to support continuous readiness, successful accreditation outcomes, and sustained compliance. The position serves as an independent and objective resource for reviewing and evaluating compliance issues and concerns. It ensures that the Board of Directors, senior management, and employees comply with regulatory requirements and organizational policies and procedures. The manager assesses organizational practices, oversees compliance investigations and corrective actions, and supervises assigned personnel using professional and supervisory discretion and independent judgment. The role manages large programs with substantial budget or organizational impact. The position is based at Adventist Health’s Roseville, California, corporate headquarters and shared-services campus. Adventist Health requires associates to receive required vaccinations as a condition of employment and annually thereafter where applicable; medical and religious exemptions may apply. The organization participates in E-Verify.

Requirements

Bachelor’s degree in nursing, business administration, hospital administration, or an equivalent combination of education and related experience.
Three years of experience in healthcare.
Two years of leadership experience in Accreditation and Regulatory.
Obtain Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certified Professional (HACP), or Lean certification within two years of hire.

Nice To Haves

Two years of experience in accreditation, regulatory compliance, or process improvement.
Five years of experience in healthcare accreditation and regulatory affairs.

Responsibilities

Review, interpret, and assist hospital departments, leadership, and Medical Staff with implementing federal, state, and Joint Commission standards and regulations.
Maintain and control regulatory, licensure, and accreditation documents and monitor compliance with Joint Commission standards.
Conduct periodic internal reviews and audits to verify that compliance procedures are followed.
Identify regulatory compliance issues requiring follow-up or investigation and manage internal investigations.
Review operational risks and develop risk-management strategies.
Disseminate written policies and procedures related to regulatory compliance.
Design and implement systems to ensure continuous regulatory, licensure, and accreditation compliance.
Support accreditation preparation by managing logistics, conducting mock surveys, and communicating regulatory compliance changes and updates.
Provide employee training on regulatory compliance topics, policies, and procedures.
Assist internal and external auditors with regulatory compliance reviews.
Prepare reports on regulatory compliance operations and progress, and monitor compliance systems for effectiveness.
Provide direction and assure regulatory compliance.
Coordinate on-site regulatory, licensure, and accreditation surveys; organize schedules and conduct internal audit processes.
Conduct an annual State regulatory compliance assessment.
Develop and maintain action plans and responses to citations from regulatory agencies.
Collect data, prepare graphic presentations, and compile reports demonstrating compliance.
Prepare and submit reports on unusual occurrences and adverse events in partnership with a network manager or network director, and alert regulatory bodies as required.
Review unusual occurrences and adverse events and ensure immediate corrective actions for reportable events to safeguard patient safety and regulatory compliance.
Supervise and direct assigned personnel.
Perform other job-related duties as assigned.