Accreditation & Regulatory Specialist

City of Hope; Goodyear (AZ); On-site; USD 95,000 - 120,000; Full time

Job summary

City of Hope seeks an Accreditation & Regulatory Specialist to lead regulatory compliance initiatives and support survey readiness across departments. The role requires translating complex TJC and CMS standards into actionable steps for clinical and administrative teams.

Ideal candidates have five years of acute-care experience, a healthcare administration or related degree, and a collaborative approach to improving patient care and compliance.

Qualifications

• Minimum education: Healthcare Administration, Healthcare, Public Health, Compliance or Nursing.
• At least five years in acute-care hospital settings with regulatory survey experience.
• Strong knowledge of TJC, CMS and other regulatory requirements.

Responsibilities

• Lead regulatory compliance activities across the organization.
• Coordinate preparation for regulatory surveys and site visits.
• Develop training materials and education for teams to ensure readiness.
• Monitor and document outcomes of quality improvement initiatives.
• Collaborate across departments to interpret changing regulations.

Skills

Regulatory compliance

TJC knowledge

CMS knowledge

Quality improvement

Hospital operations

Education

Healthcare Administration / Public Health degree

Job description

Accreditation & Regulatory Specialist

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 among the top 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:

***Shift- M-F 8:00AM-4:30PM***

The ideal candidate is an experienced acute-care healthcare professional who enjoys working collaboratively with leaders and clinical teams to promote continuous survey readiness and regulatory compliance. We are looking for someone who can take complex TJC, CMS, and other regulatory requirements and make them understandable and actionable for the teams responsible for implementing them. This person will be organized, approachable, inquisitive, and comfortable working across departments to identify opportunities, develop solutions, provide education, and prepare for regulatory surveys and site visits. Successful candidates will bring at least five years of acute-care hospital experience, strong knowledge of hospital operations and patient care, and experience participating in or preparing for regulatory surveys, along with a willingness to continually learn and apply evolving accreditation and regulatory requirements.

The Regulatory and Accreditation 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 established by federal and state regulatory bodies, national accrediting organizations, and internal policies to maintain compliance and support high-quality patient care.

This position facilitates performance quality improvement projects, scope definition, timeline development and monitoring along with documentation of outcomes to help meet accreditation and quality standards. He/she is prepared to manage small projects that are short in duration from concept to implementation, assists in the development of communication strategies related to these projects (memos, newsletter articles, Intranet site framework and content development and maintenance, etc.), as well as participate in staffing more complex projects. He/she prepares internal and external project reports through gathering, analyzing, and summarizing data and information for management. He/she is responsible for managing and archiving all project related documents for the Quality team.

He/she partners with clinical, administrative, legal, and quality teams to interpret changing regulations, guide readiness for surveys and inspections, and drive continuous improvement in compliance systems. Supports excellence, enterprise-wide initiatives, activities of the leadership team, departments, clinics, physicians, and administration.

Cross coverage as necessary for quality team.

Position Qualifications

Minimum Education: A degree in Healthcare Administration, Healthcare, Public Health, Compliance or Nursing

Minimum Experience: Experience in clinical nursing and/or quality, risk, and regulatory activities

Required Courses/Training: BLS

City of Hope is an equal opportunity employer.

City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location.