The Director of Regulatory & Accreditation is a key leadership role responsible for driving regulatory compliance and accreditation excellence across the organization. This leader will oversee strategy, readiness, and execution to ensure City of Hope consistently meets and exceeds federal, state, and accrediting body requirements-supporting our mission of delivering high-quality, safe patient care.
As a successful candidate, you will:- Lead enterprise-wide regulatory compliance and accreditation initiatives across clinical and operational areas
- Serve as the subject matter expert on regulatory standards (Joint Commission, CMS, CDPH, and others)
- Drive accreditation strategy, survey readiness, and continuous improvement efforts
- Oversee preparation for external surveys, including mock surveys and corrective action planning
- Develop and maintain policies, procedures, and documentation to ensure audit readiness
- Monitor regulatory changes and translate requirements into actionable organizational strategies
- Build dashboards, metrics, and reporting tools to track performance and compliance trends
- Partner with clinical, legal, and operational leaders to ensure alignment across the organization
- Provide leadership education and training on regulatory and accreditation requirements
- Present regulatory updates and compliance insights to senior leadership and governing bodies
Your qualifications should include: - Advanced degree in Healthcare Administration, Public Health, Nursing, or a related field (or equivalent experience)
- 3+ years of experience in clinical nursing, quality, risk, or regulatory functions
- 5+ years of progressive leadership experience
- Strong knowledge of regulatory and accrediting organizations (e.g., Joint Commission, CMS)
- Proven experience with accreditation readiness, audits, and compliance programs
- Strong analytical, communication, and leadership skills
- Experience with data analysis, performance improvement, and process optimization preferred
- Certification such as CPHQ or HACP preferred
Additional Information:
Job Status: Full time, exempt
City of Hope employees' pay is based on the following criteria: work experience, qualifications, and work location.
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