Regulatory and Accreditation Specialist - Performance Improvement

Regulatory and Accreditation Specialist – Performance Improvement 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 high‑quality 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. Responsibilities Manage small‑scale projects from concept through implementation. Assist in developing communication materials related to quality and regulatory initiatives (e.g., memos, newsletters, SharePoint or intranet content). Participate in larger, more complex projects as needed. Prepare internal and external reports by gathering, analyzing, and summarizing data for leadership and stakeholders. Manage and archive all quality‑related project documentation. Partner closely with clinical, administrative, legal, and quality teams to interpret evolving regulations, support survey and inspection readiness, and drive continuous improvement in compliance systems. Support enterprise‑wide initiatives and collaborate with leadership, departments, clinics, physicians, and administrative teams to promote regulatory excellence. Provide cross‑coverage within the Quality team as required. 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: 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 fostering 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. City of Hope is an equal opportunity employer. #J-18808-Ljbffr City of Hope