Manager, Regulatory Compliance (Hanford), Full Time, Exempt

Located in a tight-knit community in Kings County, Adventist Health Hanford has been serving the Central Valley since 1965. We are comprised of a 173-bed hospital and many outpatient clinics with primary and specialty care services. Hanford residents are proud of their city's historic charm and family-friendly atmosphere. Within an hour's travel time, Yosemite, Sequoia and Kings Canyon National Parks can be enjoyed.

Job Summary:

Manages regulatory compliance for 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. Ensures the Board of Directors, senior management and employees are in compliance with the rules and regulations of regulatory agencies, and that company policies and procedures are being followed. Facilitates regulatory compliance and risk management through comprehensive assessment of organizational practices. Supervises and directs the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment.

Job Requirements:

Education and Work Experience:

• Bachelor’s Degree or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Five years' technical experience: Preferred
• One year's leadership experience: Preferred

Essential Functions:

• Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues. Reviews operational risks and develops risk management strategies. Disseminates written policies and procedures related to compliance activities.
• Designs and implements systems to ensure a state of continual regulatory, licensure and accreditation compliance. 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.
• Provides employee training on compliance related topics, policies or procedures. Provides assistance to internal or external auditors in compliance reviews. Prepares reports regarding compliance operations and progress. Monitors compliance systems to ensure effectiveness. Provides direction assure regulatory compliance. Coordinates all on site regulatory, licensure and accreditation surveys, organizes schedules and conducts internal audit processes.
• 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.
• 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, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.