Regulatory and Accreditation Specialist – Performance Improvement

City of Hope•Zion, IL

About The Position

About City of Hope , City of Hope's mission is to make hope a reality for all touched by cancer and diabetes. Founded in 1913, City of Hope has grown into one of the largest and most advanced cancer research and treatment organizations in the U.S., and one of the leading research centers for diabetes and other life-threatening illnesses. City of Hope research has been the basis for numerous breakthrough cancer medicines, as well as human synthetic insulin and monoclonal antibodies. With an independent, National Cancer Institute-designated comprehensive cancer center that is ranked top 5 in the nation for cancer care by U.S. News & World Report at its core, City of Hope’s uniquely integrated model spans cancer care, research and development, academics and training, and a broad philanthropy program that powers its work. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and cancer treatment centers and outpatient facilities in the Atlanta, Chicago and Phoenix areas. The successful candidate: Schedule Mon - Fri, Day shift (40 hrs per week) Job Summary The Regulatory and Accreditation team member leads the strategic development, coordination, and execution of regulatory compliance and accreditation activities across the organization. This role ensures City of Hope meets or exceeds requirements set forth by federal and state regulatory bodies, national accrediting organizations, and internal policies to support compliance and deliver high‑quality patient care. This position supports performance and quality improvement initiatives by defining project scope, developing and monitoring timelines, and documenting outcomes to meet accreditation, regulatory, and quality standards. The role manages small‑scale projects from concept through implementation, assists in developing communication materials related to quality and regulatory initiatives (e.g., memos, newsletters, SharePoint or intranet content), and participates in larger, more complex projects as needed. Responsibilities include preparing internal and external reports by gathering, analyzing, and summarizing data for leadership and stakeholders, as well as managing and archiving all quality‑related project documentation. The Regulatory and Accreditation team member partners closely with clinical, administrative, legal, and quality teams to interpret evolving regulations, support survey and inspection readiness, and drive continuous improvement in compliance systems. This role supports enterprise‑wide initiatives and collaborates with leadership, departments, clinics, physicians, and administrative teams to promote regulatory excellence. Cross‑coverage within the Quality team is required as needed.

Requirements

Degree in Healthcare Administration, Healthcare, Public Health, Compliance, or Nursing required
Minimum of three (3) years of experience in clinical nursing and/or quality, risk, or regulatory functions
Demonstrates sensitivity to patient care and patient privacy
Strong interpersonal skills that promote trust and collaboration
Professional demeanor that fosters a positive organizational image
Cultural sensitivity and awareness of diversity and inclusion
Excellent verbal, written, organizational, and presentation skills
Proficiency with computer applications and software tools
Data analysis and data visualization skills
Ability to build engagement and enthusiasm for quality and compliance initiatives

Nice To Haves

Bachelor of Science in Nursing (BSN)
Healthcare Accreditation Certification Program (HACP)
Thorough knowledge of Joint Commission standards, Illinois Department of Public Health (IDPH), CMS Conditions of Participation, and other regulatory agencies

Responsibilities

Leads the strategic development, coordination, and execution of regulatory compliance and accreditation activities across the organization.
Ensures City of Hope meets or exceeds requirements set forth by federal and state regulatory bodies, national accrediting organizations, and internal policies to support compliance and deliver high‑quality patient care.
Supports performance and quality improvement initiatives by defining project scope, developing and monitoring timelines, and documenting outcomes to meet accreditation, regulatory, and quality standards.
Manages small‑scale projects from concept through implementation
Assists in developing communication materials related to quality and regulatory initiatives (e.g., memos, newsletters, SharePoint or intranet content)
Participates in larger, more complex projects as needed.
Prepares internal and external reports by gathering, analyzing, and summarizing data for leadership and stakeholders
Manages and archiving all quality‑related project documentation.
Partners closely with clinical, administrative, legal, and quality teams to interpret evolving regulations, support survey and inspection readiness, and drive continuous improvement in compliance systems.
Supports enterprise‑wide initiatives and collaborates with leadership, departments, clinics, physicians, and administrative teams to promote regulatory excellence.
Cross‑coverage within the Quality team is required as needed.