Regulatory and Quality Specialist (St. Helena)

Adventist Health•Saint Helena, CA

1d•Onsite

About The Position

Plays a key role in supporting accreditation readiness, regulatory compliance, and quality improvement activities at the facility and network level. Reporting to the Manager of Quality and Regulatory Compliance, this role assists in implementing day-to-day processes that align with the standards of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other regulatory and accrediting bodies. Responsible for performing tracers, audits, and monitoring activities that identify compliance gaps and improvement opportunities. Working closely with clinical and non-clinical staff, helps translate regulatory requirements into daily workflows, provides frontline coaching, and documents findings to ensure timely follow-up and closure of action items. Contributes to maintaining accurate regulatory documentation, survey files, and performance dashboards. Supports the preparation and logistics of external surveys and assists in compiling evidence, data, and reports that demonstrate compliance and quality outcomes. Collaborates with nursing, medical staff, and quality leaders and gathers and analyzes data related to patient safety, clinical effectiveness, and regulatory compliance. Helps track corrective action plans, supports quality improvement initiatives, and escalates risks or unresolved issues to the Manager for further action. Serves as a hands-on resource for departments, the Quality and Regulatory Specialist fosters a culture of continuous readiness, regulatory excellence, and high-quality care delivery across the organization.

Requirements

Associate's/Technical Degree or equivalent combination of education/related experience: Required
Two years' experience in healthcare: Required

Nice To Haves

Three years' experience with health care compliance and regulatory activities and two years with project management experience: Preferred
Prior experience facilitating small-scale project teams or improvement initiatives: Preferred
Exposure to Lean, Six Sigma, or other improvement methodologies: Preferred
Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire
Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP: Required

Responsibilities

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.
Coordinates logistics for regulatory and accrediting body surveys, including scheduling communications, team assignments, and preparation of materials for surveyors and internal stakeholders.
Supports the evaluation, planning and continuous readiness activities to maintain deemed status accreditation (e.g. The Joint Commission) and compliance with federal, state, and local regulatory requirements and licenses.
Administers and supports use of tracer management systems including development of tracers/audits, user assignments, report generation, training and oversight to ensure adherence to systemwide requirements.
Supports design and execution of performance improvement initiatives under the guidance of program managers or senior leaders.
Assists with project planning, team coordination, charter development, and progress tracking to ensure deliverables are achieved.
Facilitates small-scale quality and performance improvement projects aimed at enhancing clinical outcomes, efficiency, and patient experience.
Applies basic Lean, Six Sigma, PDSA, or other improvement methodologies to identify process gaps and implement corrective actions.
Collects, validates, and analyzes quality, operational, and performance data.
Prepares and presents reports, dashboards, and scorecards to leaders, committees, and frontline teams to identify trends, variation, and opportunities for improvement.
Provides basic coaching and support to staff and leaders on improvement tools, methods, and techniques.
Collaborates with interdisciplinary teams to share best practices and support adoption of standardized workflows.
Monitors improvement project outcomes and assists with follow-up actions to ensure sustainability of changes.
Documents lessons learned and promotes organizational learning to support continuous performance improvement.
Performs other job-related duties as assigned.