Manager, Regulatory and Quality

Adventist Health; Tehachapi (CA); On-site; USD 109,000 - 163,000; Full time

Job summary

Adventist Health Tehachapi Valley seeks a Manager, Regulatory and Quality for a full-time daytime role onsite in Tehachapi, CA. The position leads accreditation readiness, regulatory compliance, and quality improvement across the organization, coordinating with nursing, medical staff, and leadership to embed standards and drive performance.

Responsibilities include overseeing tracers, audits, action plans, and staff development; maintaining measurement dashboards; and guiding departments toward

Qualifications

• Bachelor’s degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement: Required
• Clinical background: Required
• Five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Preferred
• Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration: Preferred

Responsibilities

• Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy and quality initiatives.
• Leads quality and regulatory readiness activities, including surveys, action plans, and staff coaching.
• Manages daily operations of quality, patient safety, regulatory and PI programs; supervises staff and ensures alignment with system priorities.
• Leads patient safety initiatives, root-cause analyses, and risk assessments; supports event reporting and learning systems.
• Provides training and mentorship on patient safety and PI methods; fosters interdisciplinary collaboration to improve workflows.

Skills

Leadership

Quality improvement

Regulatory compliance

Patient safety

Project management

Education

Bachelor's degree (nursing or related)

Job description

Job Description

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary

Adventist Health Tehachapi Valley is seeking a Manager, Regulatory and Quality for a full-time position working 8-hour day shifts. This role is based onsite in Tehachapi, CA. We are looking for an experienced professional to lead quality improvement and regulatory compliance initiatives across the organization.

Responsible for the day-to-day coordination, implementation, and monitoring of activities that support continuous accreditation readiness, regulatory compliance, and quality improvement within the hospital. Ensures that operational practices align with the requirements of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other regulatory and accrediting bodies. Executes processes that sustain compliance with corrective action plans, prepare departments for surveys, and drive targeted performance improvement projects. This includes conducting tracers, audits, and readiness rounds; facilitating action plan development with department leaders; and coaching frontline staff to embed compliance and quality standards into everyday practice. In partnership with nursing, medical staff, and quality leaders, the Manager maintains and interprets measurement systems, dashboards, and quality indicators to track progress, identify gaps, and elevate risks. Contributes to initiatives that reduce patient harm, improve clinical effectiveness, and strengthen performance on external benchmarks such as CMS Star Ratings. Provides supervision, mentorship, and professional development to assigned staff, fostering a culture of accountability and continuous improvement. Supports survey logistics, regulatory documentation, and timely reporting, ensuring that the organization is consistently prepared for external review and positioned to achieve high-quality, safe, and compliant care delivery.

Job Requirements

Education and Work Experience:

• Bachelor’s degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement: Required
• Clinical background: Required
• Five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Preferred
• Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration: Preferred

Licenses/Certifications

• Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire

Essential Functions

• Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals. Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system. Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization’s communication regarding changes and updates for regulatory compliance.
• Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Reviews, interprets and helps hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations.
• Manages daily operations of quality, patient safety, Regulatory and performance improvement programs. Supervises and develops Quality/PI , regulatory and patient safety staff, providing mentorship, performance feedback, and coaching. Ensures alignment of local activities with system strategic priorities.
• Leads patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up. Manages site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings. Promoted a culture of safety and just culture principles within assigned entity or service line.
• Facilitates and oversees improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency. Applies Lean, Six Sigma, and other performance improvement methodologies methodology and provides coaching to leaders and teams on PI tools and techniques. Monitors project outcomes and ensures sustainability of improvements. Ensures timely collection, validation, and reporting of quality, safety, and regulatory metrics. Prepares and presents data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities. Partners with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements. Provides training and mentorship to staff on patient safety, and quality improvement methods. Fosters interdisciplinary collaboration to improve workflows and outcomes.
• Performs other job-related duties as assigned.

Organizational Requirements

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

About Us

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

JOB INFO

Job Identification : 69660

Job Category : Manager

Posting Date : 2026-08-13T22:27:11+00:00

Job Schedule : Full time

Job Shift : Day Shift

Locations : Tehachapi, CA, United States

Assignment Category : Full-time regular

Pay Range : The estimated base pay for this position is $108,913 to $163,369. Additional individual compensation may be available for this role through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information.

Hiring Department : Accreditation

Shift Length : 8 Hours