Manager of Accreditation, Regulatory and Licensing, Accreditation and Medical Library, Full-Time, Days

• 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 preferred.
• •For candidates without a relevant professional certification, willingness to obtain an agreed-upon accreditation, quality, patient safety, or regulatory credential within two (2) years of hire is preferred.

Prerequisite Skills

• •Advanced knowledge of The Joint Commission (TJC) accreditation standards and survey methodology, CMS Conditions of Participation, and California acute-care hospital licensing requirements.
• •Demonstrated ability to interpret complex regulatory and accreditation requirements and translate them into practical, measurable operational requirements and corrective actions.
• •Working knowledge of regulatory requirements applicable to hospital licensing, specialty accreditation/certification, life safety, environment of care, and healthcare construction, renovation, occupancy, and activation.
• •Demonstrated expertise in continuous survey readiness, including tracers, mock surveys, regulatory audits, gap assessments, evidence review, plans of correction, and validation of sustained compliance.
• •Strong regulatory risk assessment and problem-solving skills, including data analysis, root-cause analysis, trend identification, performance improvement, and timely escalation of material or recurring risk.
• •Demonstrated project and program management skills, including development of work plans, prioritization, assignment of accountability, milestone and deadline management, escalation, and verification of closure.
• •Ability to lead complex, multidisciplinary regulatory initiatives and influence executives, physicians, clinical leaders, facilities professionals, and frontline teams without relying solely on positional authority.
• •Strong knowledge of policy and procedure governance, including regulatory review, approval processes, implementation, maintenance, and organizational accountability.
• •Advanced written, verbal, presentation, facilitation, and consultation skills, with the ability to communicate complex regulatory requirements and organizational risk clearly to audiences ranging from frontline staff to executive leadership and governance bodies.
• •Demonstrated ability to develop and communicate regulatory dashboards, readiness metrics, findings, trends, and executive-level reports that support informed decision-making.
• •Strong judgment, discretion, organization, and attention to detail, with demonstrated ability to manage multiple high-priority regulatory activities and deadlines in a complex, 24/7 acute-care environment.
• •Ability to maintain accurate, organized, audit-ready regulatory records and evidence supporting accreditation, licensing, surveys, corrective actions, and regulatory submissions.
• •Demonstrated ability to foster accountability, collaboration, respectful challenge, transparency, and service excellence consistent with MarinHealth C.A.R.E.S. standards.

Primary Customer Served (Age Specific)

• •This role is not patient/family facing role
• •This role's primary customer are adult staff, managers, physicians and provider leaders

Patient Privacy (HIPAA Compliance):

• •This role is not a patient care role
• •This role upholds HIPAA compliance when interfacing with regulators and others

• Duties And Responsibilities:
• Essential Duties (Not Modifiable)
• Accreditation Management

• •Lead medical center accreditation activities, including The Joint Commission surveys, CMS validation surveys, and other accrediting body reviews.
• •Provide accreditation consultation to specialty accreditation teams such as Trauma, Cancer Institute, TJC Disease certifications for Stroke and Diabetes, CA Children’s Services (CCS), etc.
• •Develop and maintain a comprehensive accreditation readiness program that supports continuous survey preparedness.
• •Monitor and communicate accreditation standards and regulatory changes to hospital leadership and operational teams and consult on plans to meet new standards and regulations.
• •Coordinate document reviews, tracer activities, mock surv