Program Manager, Accreditation and Regulatory Compliance (White Memorial)

Adventist Health; Los Angeles (CA); On-site; USD 80,000 - 100,000; Full time

Job summary

Adventist Health seeks a Compliance Lead in Los Angeles, California to oversee the Accreditation and regulatory compliance program. This role involves ensuring compliance with laws and standards and conducting internal reviews and audits. Candidates should possess a Bachelor's degree in nursing or business administration and have at least three years of experience in healthcare, with a preference for those with accreditation and regulatory compliance experience. The position also requires certifications like CPHQ and Lean, with responsibilities including training and managing compliance issues.

Qualifications

• Bachelor’s degree in nursing or related field.
• Three years’ experience in healthcare is required.
• Preferred: Two years’ experience in accreditation or regulatory compliance.

Responsibilities

• Leads the Accreditation and regulatory compliance program.
• Reviews and interprets standards and regulations.
• Maintains regulatory, licensure and accreditation documents.

Education

Bachelor’s degree in nursing, business administration, hospital administration or equivalent

Certified Professional in Healthcare Quality (CPHQ)

Healthcare Accreditation Certified Professional (HACP)

Lean certification

Tools

Lean or Six Sigma Green Belt certification

Job description

Job Summary

Leads the Accreditation and regulatory compliance program of the organization. Ensures organizational compliance with applicable laws and standards, and government regulations. Functions as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. Provides oversight of regulatory risk, and survey readiness strategy, in alignment with system Accreditation, regulatory and licensing strategic priorities.

Job Requirements

• Bachelor’s degree in nursing, business administration, hospital administration or equivalent combination of education/related experience.
• Three years’ experience in healthcare.
• Preferred: Two years’ experience in accreditation or regulatory compliance or process improvements.
• Preferred: Five years’ experience in healthcare accreditation and regulatory affairs. Minimum two years of leadership experience in Accreditation and Regulatory.

Licenses/Certifications

• Certified Professional in Healthcare Quality (CPHQ) or Healthcare Accreditation Certified Professional (HACP) certification or Lean certification required within two years of hire.
• Certified Professional in Healthcare Quality (CPHQ) or HACP or Lean or Six Sigma Green Belt (LGB) required.

Essential Functions

• Reviews, interprets and assists hospital departments, leadership and Medical Staff in implementation of federal, state and Joint Commission standards and regulations.
• Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance and conducts internal reviews and audits to ensure procedures are followed.
• Identifies regulatory compliance issues and manages internal investigations of compliance issues. Reviews operational risks and develops risk management strategies.
• Disseminates written policies and procedures related to regulatory compliance activities.
• Designs and implements systems to ensure continual compliance. Supports accreditation preparation by managing logistics, conducting mock surveys and maintaining communication regarding regulatory changes.
• Provides employee training on regulatory compliance topics. Assists internal or external auditors in compliance reviews. Prepares reports and monitors compliance system effectiveness.
• Coordinats on‑site regulatory, licensure and accreditation surveys; organizes schedules and conducts internal audit processes.
• Conducts annual state regulatory compliance assessment. Develops action plans and responses to citations for any regulatory agency. Collects data, compiles reports and demonstrates compliance.
• Prepares and submits reports following the review of unusual occurrences and adverse events. Alerts appropriate regulatory bodies as required.
• Performs other job‑related duties as assigned.

Organizational Requirements

Adventist Health requires 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.