Manager, Regulatory and Quality (Clearlake)

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:

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 escalate 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
• 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. 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 assists 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 in