Accreditation & Regulatory Compliance Lead

Marin General Hospital dba MarinHealth Medical Center; United States; On-site; USD 208,569,000 - 312,853,000; Full time

Job summary

MarinHealth Medical Center seeks an experienced Accreditation, Regulatory & Licensing Manager to provide strategic leadership for accreditation readiness and regulatory compliance across MarinHealth Medical Center. You will serve as a subject matter expert for TJC, CMS COP, CDPH, and other regulatory bodies, translating complex requirements into actionable plans.

With executive partnership, you will drive readiness, survey responses, corrective actions, and licensing activities, while partnering

Qualifications

• Bachelor’s degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or a related field required.
• Master’s degree in nursing, Healthcare Administration, Public Health, Business Administration, or related healthcare field preferred.
• 5–7 years of progressively responsible experience in healthcare accreditation, regulatory compliance, quality management, licensing, patient safety, or related function required.
• Experience supporting or leading TJC, CMS, CDPH, or other regulatory surveys/inspections in an acute care hospital required.
• Demonstrated experience leading regulatory readiness, gap assessment, corrective action, and complex cross-functional projects required.
• Clinical experience in a California acute care hospital preferred.
• Experience with trauma, NICU, behavioral health, specialty certification, plans of correction, regulatory agency interaction, and/or healthcare construction/activation preferred.
• Leadership or program-management experience with demonstrated ability to influence outcomes across functions preferred.

Responsibilities

• Lead accreditation activities, including The Joint Commission surveys, CMS validation surveys, and other accrediting body reviews.
• Provide accreditation consultation to specialty accreditation teams such as Trauma, Cancer Institute, and others.
• Develop and maintain a comprehensive accreditation readiness program.
• Monitor regulatory changes and communicate them to leadership; consult on plans to meet new standards.
• Coordinate document reviews, tracer activities, mock surveys, gap assessments, corrective action plans, and evidence collection.
• Prepare executive leadership and staff for announced and unannounced surveys.

Skills

Regulatory Leadership

Project Management

Communication

Data Analysis

Education

Bachelor's degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or related field

Master's degree preferred

Job description

MarinHealth Medical Center seeks an experienced Accreditation, Regulatory & Licensing Manager to provide strategic leadership for accreditation readiness and regulatory compliance across MarinHealth Medical Center. You will serve as a subject matter expert for TJC, CMS COP, CDPH, and other regulatory bodies, translating complex requirements into actionable plans.

With executive partnership, you will drive readiness, survey responses, corrective actions, and licensing activities, while partnering