Regulatory and Accreditation Specialist - Performance Improvement

Schedule

• Mon - Fri, Day shift (40 hrs per week)

Job Summary

The Regulatory and Accreditation team member leads the strategic development, coordination, and execution of regulatory compliance and accreditation activities across the organization. This role ensures City of Hope meets or exceeds requirements set forth by federal and state regulatory bodies, national accrediting organizations, and internal policies to support compliance and deliver highquality patient care.

This position supports performance and quality improvement initiatives by defining project scope, developing and monitoring timelines, and documenting outcomes to meet accreditation, regulatory, and quality standards.

The role manages smallscale projects from concept through implementation, assists in developing communication materials related to quality and regulatory initiatives (e.g., memos, newsletters, SharePoint or intranet content), and participates in larger, more complex projects as needed. Responsibilities include preparing internal and external reports by gathering, analyzing, and summarizing data for leadership and stakeholders, as well as managing and archiving all qualityrelated project documentation.

The Regulatory and Accreditation team member partners closely with clinical, administrative, legal, and quality teams to interpret evolving regulations, support survey and inspection readiness, and drive continuous improvement in compliance systems. This role supports enterprisewide initiatives and collaborates with leadership, departments, clinics, physicians, and administrative teams to promote regulatory excellence. Crosscoverage within the Quality team is required as needed.

Position Qualifications

Minimum Education

• Degree in Healthcare Administration, Healthcare, Public Health, Compliance, or Nursing required

Minimum Experience

• Minimum of three (3) years of experience in clinical nursing and/or quality, risk, or regulatory functions

Preferred Qualifications

Education

• Bachelor of Science in Nursing (BSN)

Certification

• Healthcare Accreditation Certification Program (HACP)

Experience

• Thorough knowledge of Joint Commission standards, Illinois Department of Public Health (IDPH), CMS Conditions of Participation, and other regulatory agencies

Skills & Abilities

• Demonstrates sensitivity to patient care and patient privacy

• Strong interpersonal skills that promote trust and collaboration

• Professional demeanor that fosters a positive organizational image

• Cultural sensitivity and awareness of diversity and inclusion

• Excellent verbal, written, organizational, and presentation skills

• Proficiency with computer applications and software tools

• Data analysis and data visualization skills

• Ability to build engagement and enthusiasm for quality and compliance initiatives