Regulatory and Compliance Specialist

University of California- Davis Health; Sacramento (CA); Hybrid; USD 88,000 - 161,000; Full time

Benefits offered by this job

Hybrid work model

Benefits eligible

Job summary

University of California, Davis Health is seeking a Regulatory, Licensure & Accreditation professional to serve as an internal subject matter resource for TJC, CMS, CDPH, and Title 22/24 requirements.

The role coordinates licensure and accreditation activities, ensures survey readiness, and develops plans to achieve timely, accurate outcomes across clinical, operational, and administrative areas.

Qualifications

• Bachelor's degree in science or equivalent work experience.
• Experience in regulatory, licensure, and accreditation within a hospital setting.
• Proficiency in Microsoft Office programs (Excel, PowerPoint, Word, Outlook).
• Experience teaching, training, or public speaking.
• Experience in project management.
• Epic EMR experience.
• Leadership experience in an academic healthcare setting.
• Strong writing skills for complex documents.
• Analytical judgment and decision-making in high-stakes environments.
• Knowledge of The Joint Commission, CMS, CDPH, and Title 22/24 standards.

Responsibilities

• Coordinate and support regulatory, licensure, and accreditation activities.
• Prepare for surveys, inspections, and regulatory reviews.
• Provide internal guidance on expectations, timelines, and readiness activities.
• Represent the organization in communications with regulatory bodies.
• Develop day-to-day priorities and longer-range plans.

Skills

Regulatory compliance

Project management

Microsoft Office

Public speaking

Leadership

Epic EMR

Analytical judgment

Data analysis

Education

Bachelor's degree in science

Tools

Epic EMR

Microsoft Office (Excel, PowerPoint, Word, Outlook)

Job description

Job ID: 88598
Location: Sacramento
Full Time

Job Summary

Under the general direction of the Chief Medical Officer and Director of Regulatory, Licensure & Accreditation, the position serves as an internal subject matter resource for The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), California Department of Public Health (CDPH), and California Code of Regulations Title 22 requirements.

The position coordinates and supports organizational licensure and accreditation activities, including survey readiness, accreditation surveys, licensing inspections, regulatory reviews, and associated follow-up activities. The position independently establishes day-to-day priorities and develops longer-range plans to ensure timely, accurate, and high-quality outcomes.

The role requires a high degree of analytical judgment, initiative, organizational expertise, political acumen, and independent decision‑making, particularly when coordinating complex activities across multiple clinical, operational, and administrative areas. The position also requires advanced written and verbal communication skills and the ability to effectively represent the organization in public‑facing interactions with regulatory, licensing, and accrediting agencies.

Minimum Qualifications

• Bachelor's degree in science or other appropriate degree program or equivalent work experience
• Experience working in regulatory, licensure, and accreditation and/or operational management in a hospital.
• Experience and knowledge in all Microsoft Office Programs: Excel, PowerPoint, Word, and Outlook.
• Experience teaching, training, or public speaking.
• Experience in project management.
• Epic EMR experience.
• Leadership experience in an academic healthcare setting.
• Expert writing skills and the ability to quickly create accurate, easily understood documents for internal and external use.
• Expert in analytical judgement, political acumen, and decision‑making skills in a high‑stakes environment.
• Knowledge of The Joint Commission, Centers for Medicare & Medicaid, Office of Human Research Protection/National Institute of Health standards, California Administrative Code Title 22 and Title 24 Regulations, and other regulatory and accreditation agency criteria for performance improvement and resource analysis.
• Skills to perform statistical analyses and present data and information in a clear and concise report format.
• Ability to use performance improvement methods and utilize quality tools (RCA, FEMA, etc.) for retrospective and concurrent reviews.
• Analytical skills to identify areas for resource improvement and develop action plans.

Preferred Qualifications

• Minimum five (5) years of experience working in a health care organization.
• Experience in a large academic healthcare setting.
• Experience with internal/external auditing practices.
• Project Management Professional (PMP) or Lean Six Sigma experience.

Key Responsibilities

• 30% - THE JOINT COMMISSION ACCREDITATION ACTIVITIES
• 30% - CDPH AND CMS CERTIFICIATION & LICENSING ACTIVITIES
• 20% - INTERNAL ROUNDING, CONSULTING AND EDUCATION ACTIVITES
• 10% - REGULATORY AND ACCREDITATION ACTIVITES
• 10% - ANALYTICS AND DATA

Department Overview

The Department of Regulatory, Licensure & Accreditation provides organizational oversight, coordination, and support for regulatory compliance, accreditation, and licensure requirements affecting UC Davis Medical Center. The department works across clinical, operational, and administrative areas to promote continuous readiness, facilitate regulatory and accreditation surveys and inspections, and ensure timely response to identified findings and requirements.

The department serves as a central resource for interpreting and communicating applicable regulatory and accreditation standards and coordinating organizational activities associated with external oversight. This includes collaboration with executive leadership, clinical and administrative departments, Medical Staff leadership, and regulatory and accrediting agencies.

The department's work is critical to maintaining the Medical Center's licensure, accreditation, regulatory compliance, and ability to demonstrate adherence to required standards of quality and patient safety.

Department Specific Job Scope

The position provides enterprise-wide coordination and subject matter expertise for regulatory, licensure, and accreditation activities. The role is responsible for coordinating survey and inspection schedules, supporting organizational readiness, facilitating communication and information exchange among internal stakeholders and external regulatory, accrediting, and licensing agencies, including monitoring activities required to maintain compliance.

The position independently manages multiple concurrent priorities associated with regulatory, licensing, and accreditation activities and works across departments to coordinate preparation, documentation, logistics, follow‑up, and resolution of issues identified through surveys, inspections, and regulatory reviews.

The position serves as a key internal resource for interpreting and applying regulatory, licensure, and accreditation requirements, including guiding leaders and operational areas regarding expectations, timelines, documentation, and readiness activities. The role requires the ability to navigate complex organizational relationships, exercise sound judgment, prioritize competing demands, and communicate effectively with both internal stakeholders and external surveyors, inspectors, and regulatory representatives.

POSITION INFORMATION

• Salary or Pay Range: $3,375.48 - $6,210.73
• Salary Frequency: Biweekly
• Salary Grade: Grade 23
• UC Job Title: REGL AND CMPLNC HC SPEC 3
• UC Job Code: 004207
• Number of Positions: 1
• Appointment Type: Staff: Career
• Percentage of Time: 100%
• Shift (Work Schedule): Monday-Friday, 8 am - 5 pm
• Location: North Addition Office Building (HSP002)
• Union Representation: 99 - Non-Represented (PPSM)
• Benefits Eligible: Yes
• This position is hybrid (mix of on-site and remote work)

Benefits

Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility by visiting UCnet Benefits Page or Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees.

• High quality and low-cost medical plans to choose from to fit your family's needs
• UC pays for dental and vision coverage for you and your family
• Retirement plans for eligible employees including Pension and other Retirement Saving Plans
• Supplemental insurance offered including additional life, short/long term disability, pet insurance, legal coverage, accident, critical illness and hospital indemnity
• Pregnancy and Parental Leave, Family & Medical Leave, Adoption Assistance and Pay for Family Care and Bonding for eligible employees
• Lactation Support Program and Family Care discounts and resources
• Employee Well-being resources and programming to support thriving in all aspects of employee's lives
• On-site Employee Assistance Program including access to free mental health services
• Generous amount of paid Holidays annually as outlined in the UC Policies or Collective Bargaining Agreements
• Paid Time Off/Vacation/Sick Time as outlined in the UC Policies or Collective Bargaining Agreements
• Continuing Education (CE) allowance and Staff Education Reimbursement Program for eligible employees
• Access to free professional development courses and learning opportunities for personal and professional growth
• Public Service Loan Forgiveness (PSLF) Qualified Employer and Student Loan Debt Counseling Program for eligible employees

Physical Demands

• Standing - Frequent 3 to 6 Hours
• Walking - Frequent 3 to 6 Hours
• Sitting - Frequent 3 to 6 Hours
• Lifting/Carrying 0-25 Lbs - Occasional Up to 3 Hours
• Lifting/Carrying 26-50 lbs - Occasional Up to 3 Hours
• Pushing/Pulling 0-25 Lbs - Occasional Up to 3 Hours
• Pushing/Pulling 26-50 lbs - Occasional Up to 3 Hours
• Bending/Stooping - Frequent 3 to 6 Hours
• Squatting/Kneeling - Frequent 3 to 6 Hours
• Twisting - Occasional Up to 3 Hours
• Climbing (e.g., stairs or ladders) - Occasional Up to 3 Hours
• Reaching overhead - Frequent 3 to 6 Hours
• Keyboard use/repetitive motion - Frequent 3 to 6 Hours

Environmental Demands

• Chemicals, dust, gases, or fumes - Occasional Up to 3 Hours
• Loud noise levels - Occasional Up to 3 Hours
• Marked changes in humidity or temperature - Occasional Up to 3 Hours
• Microwave/Radiation - Occasional Up to 3 Hours
• Operating motor vehicles and/or equipment - Occasional Up to 3 Hours
• Uneven Surfaces or Elevations - Occasional Up to 3 Hours

Mental Demands

• Sustained attention and concentration - Frequent 3 to 6 Hours
• Complex problem solving/reasoning - Frequent 3 to 6 Hours
• Ability to organize & prioritize - Frequent 3 to 6 Hours
• Communication skills - Continuous 6 to 8+ Hours
• Numerical skills - Frequent 3 to 6 Hours
• Constant Interaction - Continuous 6 to 8+ Hours
• Customer/Patient Contact - Frequent 3 to 6 Hours
• Multiple Concurrent Tasks - Continuous 6 to 8+ Hours

Work Environment

UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space.

Special Requirements

• This is a critical position, as defined by UC Policy and local procedures, and as such, employment is contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance and functional capacity assessment
• This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures and training requirements

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

A Culture of Opportunity and Belonging

At UC Davis, we're committed to solving life's most urgent challenges and building a healthier, more resilient world. We believe in growing through every challenge, continually striving to improve, and welcoming new perspectives that strengthen our community. We recognize that a vibrant and innovative organization values both individual strengths and shared purpose. The best ideas often emerge when people with different experiences come together.

As you consider joining UC Davis, we invite you to explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education. We believe you belong here. The University of California, Davis is an Equal Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

To view the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

Because we want you to feel seen and valued, our recruitment process at UC Davis supports openness and authenticity. Research shows that some individuals hesitate to apply unless they meet every qualification. You may be an excellent fit for this role-or the next one. We encourage you to apply even if your experience doesn't match every listed requirement. #YouBelongHere

To learn more about our background check program, please visit: https://hr.ucdavis.edu/departments/recruitment/ucd/selection/background-checks