ABOUT MARINHEALTH
Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.
MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others.
Company:
Marin General Hospital dba MarinHealth Medical Center
Compensation Range:
$72.79 - $109.19
Work Shift:
8 Hour (days) (United States of America)
Scheduled Weekly Hours:
40
Job Description Summary:
The Accreditation, Regulatory & Licensing Manager provides strategic leadership and operational management for continuous accreditation, regulatory, and clinical licensing readiness across MarinHealth Medical Center. The role serves as an organizational subject matter expert for The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS) conditions of participation (COP), California Department of Public Health (CDPH), California Department of Health Care Access and Information (HCAI), California Department of Health Care Services (DHCS), local health authorities, California Children’s Services (CCS), behavioral health licensing requirements, and other applicable accrediting or regulatory bodies. With QMS Executive Director leadership, the Manager translates complex requirements into clear operational expectations; leads enterprise readiness, survey response, corrective action, and licensing activities; identifies and escalates regulatory risk; and partners with executive leadership, medical staff, clinical and operational leaders to sustain compliance, patient safety, and a culture of continuous improvement.
Job Requirements, Prerequisites and Essential Functions:
Education
Bachelor’s degree in nursing, Healthcare Administration, Public Health, Quality Management, Regulatory Affairs, or a related field required.
Master’s degree in nursing, Healthcare Administration, Public Health, Business Administration, or a related healthcare field preferred.
Experience
Five (5) to seven (7) years of progressively responsible experience in healthcare accreditation, regulatory compliance, quality management, licensing, patient safety, or a related healthcare operational function required.
Experience supporting or leading TJC, CMS, CDPH, or other regulatory surveys/inspections in an acute care hospital required.
Demonstrated experience leading regulatory readiness, gap assessment, corrective action, and complex cross-functional projects required.
Clinical experience in a California acute care hospital preferred.
Experience with trauma, NICU, behavioral health, specialty certification, plans of correction, regulatory agency interaction, and/or healthcare construction/activation preferred.
Leadership or program-management experience with demonstrated ability to influence outcomes across functions preferred.
Licenses & Certifications
California Registered Nurse license preferred when relevant to the candidate’s clinical background.
CPHQ, CJCP, CPPS, Lean Six Sigma, Healthcare Construction Certificate (HCC), or comparable accreditation/quality/regulatory credential…