Manager, Regulatory and Quality (Portland)

Adventist Health Portland; Portland (OR); On-site; USD 85,000 - 110,000; Full time

Job summary

Adventist Health Portland is seeking a Manager for regulatory compliance to lead accreditation readiness and quality improvement initiatives. You will work closely with nursing and medical staff to ensure compliance with healthcare regulations, develop staff, and contribute to patient safety.

The role requires a Bachelor’s degree in nursing or related field, three years of experience in compliance, and a clinical background. Ideal candidates will have Lean or Six Sigma certification.

Qualifications

• Required Bachelor's degree in nursing, business administration, or equivalent.
• Three years' experience in accreditation or regulatory compliance.
• Required clinical background.

Responsibilities

• Coordinate activities for continuous accreditation readiness.
• Ensure regulatory compliance and quality improvement.
• Supervise staff and develop professional skills.

Skills

Regulatory compliance

Quality improvement

Patient safety

Lean/Six Sigma

Education

Bachelor's degree in nursing or related field

Lean or Six Sigma Green Belt

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.

Job Summary

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 CMS, the Joint Commission, state agencies, and other regulatory and accrediting bodies. Executes processes that sustain compliance with corrective action plans, prepares departments for surveys, and drives 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

• Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulatory 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
• Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP: Required

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.
• 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 systems.
• Manages a team of professionals who safeguard facility licensing status, maintain accreditations, and assure compliance with healthcare regulations.
• Supports the accreditation preparation process by managing logistics, conducting mock surveys, and communicating regulatory updates.
• Conducts annual state regulatory compliance assessment and develops response action plans for citations.
• Manages daily operations of quality, patient safety, regulatory and performance improvement programs; supervises and develops staff; ensures alignment with strategic priorities.
• Leads patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow‑up.
• Facilitates and oversees improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency using Lean, Six Sigma, and other methodologies.
• Monitors project outcomes, ensures sustainability, and reports metrics to leadership and committees.
• 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.