Director, Accreditation & Regulatory Readiness

MarinHealth; Greenbrae Boardwalk (CA); On-site; USD 99,000 - 150,000; Full time

Job summary

MarinHealth seeks an Accreditation, Regulatory & Licensing Manager to provide strategic leadership and operational management for continuous accreditation and licensing readiness across MarinHealth Medical Center. This role partners with executive leadership, medical staff, and facilities to sustain compliance, patient safety, and improvement culture.

The position requires a Bachelor's in a related field, 5–7 years in healthcare accreditation, and strong knowledge of TJC, CMS, and state

Qualifications

• Bachelor’s degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or related field required.
• Master’s degree in nursing, Healthcare Administration, Public Health, Business Administration, or related healthcare field preferred.
• 5–7 years of progressive experience in healthcare accreditation, regulatory compliance, quality management, licensing, patient safety, or related healthcare operational 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.

Responsibilities

• Lead accreditation activities, including The Joint Commission surveys, CMS validation surveys, and other reviews.
• Develop and maintain an accreditation readiness program for continuous survey preparedness.
• Monitor regulatory changes and advise leadership on meeting new standards.
• Coordinate document reviews, tracer activities, mock surveys, gap assessments, corrective actions, and evidence.
• Prepare leadership for announced and unannounced surveys; manage licensing activities and reports.
• Collaborate with legal, compliance, and quality teams to mitigate regulatory risk.
• Lead licensing oversight for general acute care hospital licensure, NICU, trauma, and other services.
• Develop dashboards and reports on readiness metrics for governance.
• Educate leaders on regulatory requirements and provide consulting on policy updates.

Skills

Regulatory compliance

Regulatory readiness

Project management

Data analysis

Policy & procedure governance

Communication skills

Leadership

Education

Bachelor's degree

Master's degree

Job description

MarinHealth seeks an Accreditation, Regulatory & Licensing Manager to provide strategic leadership and operational management for continuous accreditation and licensing readiness across MarinHealth Medical Center. This role partners with executive leadership, medical staff, and facilities to sustain compliance, patient safety, and improvement culture.

The position requires a Bachelor's in a related field, 5–7 years in healthcare accreditation, and strong knowledge of TJC, CMS, and state