Director of Regulatory & Accreditation Leadership

El Camino Health; Mountain View (CA); Hybrid; USD 188,000 - 282,000; Full time

Job summary

El Camino Health in Mountain View seeks a Director of Accreditation, Regulatory & Licensure to lead enterprise-wide compliance with Joint Commission, CMS, and CDPH standards. You will oversee licensure processes, survey readiness, and regulatory reporting, partnering with clinical and executive leaders to drive quality and safety.

The role requires a nursing or clinical healthcare degree, advanced degree preferred, and substantial leadership experience in accreditation programs, change

Qualifications

• Degree in Nursing or clinical healthcare field preferred.
• Master's degree in Nursing or healthcare-related field preferred.
• 5+ years of operations management experience preferred.
• 3+ years recent experience with Joint Commission survey preparation and continuous survey readiness.
• Extensive knowledge of accreditation standards applicable to Hospital, Long Term Care, and Behavioral Health.
• Experience with CMS, State and Joint Commission surveys.
• Experience leading change and designing and improving workflow/work processes.
• Experience with PDCA and Lean Six Sigma.
• Experience in staff education and effective communication and presentation skills.
• Demonstrated abilities in project management, analytical interpretation and critical thinking.
• Current license as a Registered Nurse in California, preferred.
• CPHQ, preferred.

Responsibilities

• Serve as the primary contact for regulatory agencies and manage on-site regulatory activities.
• Assist with CMS QAPI standards and the Patient Safety Plan development.
• Lead survey preparation, responses, and corrective action plans.
• Educate leaders on regulatory changes and compliance requirements.
• Collaborate with staff to maintain certifications and improve care across service lines.

Skills

Regulatory knowledge

Leadership

Project management

Lean Six Sigma

Process improvement

Communication skills

Analytical thinking

Education

Nursing or healthcare-related degree

Master's degree in Nursing or healthcare-related field

Tools

PDCA / Lean Six Sigma

Job description

El Camino Health in Mountain View seeks a Director of Accreditation, Regulatory & Licensure to lead enterprise-wide compliance with Joint Commission, CMS, and CDPH standards. You will oversee licensure processes, survey readiness, and regulatory reporting, partnering with clinical and executive leaders to drive quality and safety.

The role requires a nursing or clinical healthcare degree, advanced degree preferred, and substantial leadership experience in accreditation programs, change