System Accreditation and Regulatory Specialist

Education and Work Experience:

• Associate’s/Technical Degree or equivalent combination of education/related experience: Required


• Two years' experience in healthcare: Required


• Three years' experience with health care compliance and regulatory activities and two years' experience with project management: Preferred

Essential Functions:

• Conducts regulatory compliance reviews and audits for hospitals, Rural Health Clinics (RHC) and outpatient clinics in collaboration with system AR&L and Ambulatory leadership. Supports systemwide chart audits and virtual chart reviews focused on: High-risk regulatory issues, Identified survey trends, other identified regulatory non-compliance. Tracks, reviews and provide feedback on mock survey action plans and corrective action strategies. Supports CMS plan of correction review process, including: Initial review of action plans, Coordination with System Director for final review and approval. Participates as needed and support system and site-level mock surveys for designated hospitals and ambulatory locations. Provides chart audit support during mock surveys. Assists in Focused Survey Assessment (FSA) implementation and survey readiness initiatives in collaboration with the System Director. Supports implementation and maintenance of Focused High-Risk Tracer processes. Assists with Focused Tracer schedule implementation across sites. Participates in site visits to assess regulatory compliance and provide recommendations for improvement as needed.


• Provides education and consultation to hospital and clinic teams based on chart audit findings, tracer results, and survey trends. Supports regulatory readiness by educating leaders and staff on: CMS Conditions of Participation, Joint Commission standards, State licensing requirements and other applicable regulations. Assists with orientation to regulatory database such as RLDatix for new leaders and promote effective use of the platform to support survey readiness.


• Supports transition of hospitals to Joint Commission accreditation, including readiness reviews and coordination with site leaders. Maintains the systemwide sites and services grid for all Adventist Health facilities. Serves as a Regulatory readiness platform (such as RLDatix) subject matter expert, supporting systemwide adoption and effective utilization for survey readiness. Assists markets with: Tracer documentation, action plan tracking, survey readiness documentation management.


• Collaborates with system clinical and operational teams to develop, review, and maintain systemwide policies and procedures that support regulatory compliance and best practices. Supports regulatory integration into system governance structures and improvement initiatives. Assists with development and maintenance of survey readiness tools. Provides support for system regulatory initiatives and strategic compliance projects. Participates in special projects and regulatory initiatives as assigned by the System Director.


• Travel required to support site visits, mock surveys, and regulatory readiness activities across Adventist Health markets.


• 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 as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.