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ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Regulatory Affairs, Accreditation & Licensing Specialist

REPORTS TO POSITION:Regulatory Affairs, Accreditation & Safety Manager

DEPARTMENT: Quality Management

DATE LAST REVIEWED: September 2026

OUR VISION: Creating America's healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring, Safety, and Teamwork

DEPARTMENT SUMMARY: The Quality Management department provides essential services to St. Charles Health System (SCHS) including: quality improvement expertise and support; data analysis; regulatory affairs, accreditation and licensing expertise and support; environment of care safety programming, expertise, and support; emergency preparedness; policy and document library management and support; data abstraction; integrity of clinical documentation; and the patient experience and grievance program.

POSITION OVERVIEW: The Regulatory Affairs, Accreditation & Licensing Specialist provides regulatory expertise as related to Joint Commission, CMS, Oregon Health Authority, Pharmacy Board, OSHA, and other regulatory agencies. This is a collaborative role that works cross-functionally with all St. Charles Health System departments, including a close partnership with the Quality Management and St. Charles Health System Leadership teams to ensure submission of proper documentation, compliance to standards, completion of requirements for improvement, and reporting timelines are met for all regulatory required activities. The Specialist actively coordinates continuous survey readiness, regulatory functions, licensing, and emergency preparedness for St. Charles Health System.

This position does not directly manage other caregivers, however, may be asked to review and provide feedback on the work of other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Organizes, prepares, and leads the hospitals' Joint Commission, Oregon Health Authority, CMS, OSHA, and other required regulatory programs for SCHS.

Conducts tracers and compliance assessments to monitor survey readiness and regulatory risk. Leads preparation for regulatory surveys, inspections, licensing reviews, and unannounced visits; serves as liaison with regulatory agencies. Manages regulatory reporting and submissions, including Joint Commission systems, licensure documentation, and required follow-up actions.

Interprets and applies Oregon staffing laws and regulations, providing guidance to leaders on operational impact, compliance requirements, and risk mitigation strategies. Supports and advises staffing committees, including regulatory requirements, documentation standards, and compliance expectations. Evaluates staffing plans, staffing variances, and compliance data to identify trends, risks, and opportunities for improvement. Reviews and analyzes staffing complaints from regulatory agencies and manages response development and submission to OHA. Tracks, analyzes, and facilitates response to regulatory fines and penalties.

Works with the Regulatory Affairs, Accreditation & Safety Manager to manage the Joint Commission web-based application for accredited facilities and programs. Maintains the reporting interface and database with current information and routinely updates for changes. Continually assesses the standards and ensures that the organization is conducting regular audits to meet regulatory standards.

Assists in record keeping of all required regulatory, accreditation and licensing for SCHS. Performs assessment and license review and submission for hospital-based construction projects per OHA, OSHA and FGI standards in conjunction with the Construction Project Management Team.

Submits sentinel and patient safety events in the Joint Commission web-based application. Monitors and tracks team progress on goals set by Joint Commission for measures of success.

Serves as a resource for all regulatory requirements throughout St. Charles Health System, including OHA and CMS Conditions of Participation. Informs and educates the organization, including the organized medical staff, on new and changing regulatory standards.

Serves as point person and communication liaison for all regulatory agencies during surveys/inspections and hospital leadership.

Audits hospital and department compliance with standards using various methods, such as direct observation, chart review, data analysis, mock surveys, and tracers. Supports efforts to submit monthly, quarterly, semi-annual, and annual regulatory required performance reports.

Works with the Regulatory Affairs, Accreditation & Safety Manager to convene various quality improvement committees and work groups, set agenda to drive desired meeting outcomes (based on contract and accreditation requirements), and ensure proper recording of committee activities. Conducts reporting of regulatory quality initiatives and follow up with all site Patient Safety and Quality Committees.

Leads/assists efforts to identify improvement opportunities, corrective actions, and plans for sustaining change. Ensures audit data is identified appropriately and ensures departments work to address corrective actions and plans are implemented. Follows up on plans to ensure sustainment of plans.

Performs various quality department functions and processes, such as quality of care complaint/adverse event review and assessment of medical record review results and recommend actions to address any identified improvement opportunities.

Makes recommendations on matters of policy in area of expertise.

Supports the vision, mission, and values of the organization in all respects.

Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients, and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:

Required: Bachelor's degree in related field or a combination of education and experience.

Preferred: Master's degree in related field. Formal training in lean, process improvement, accreditation and licensing.

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Certified Professional in Healthcare Quality within one (1) year.

Health Accreditation Certification Program within two (2) years.

FEMA Certificates for IS-100, IS-200, IS-700, IS-800 courses within two (2) years.

Valid Oregon driver's license and ability to meet St. Charles Health System driving requirements. (This position is required to travel to other locations).

Preferred: CPHQ, Certificates for IS-100, IS-200, IS-700, IS-800.

EXPERIENCE:

Required: Minimum two (2) years experience in healthcare accreditation, regulatory compliance, quality, or related healthcare operations. Experience in interpreting regulatory standards and supporting survey readiness activities.

Preferred: Clinical and/or advanced experience with Joint Commission, CMS Conditions of Participation, OHA and OSHA. Experience mentoring accreditation and regulatory professionals. Knowledge of NIMS, HICS and FEMA exercise design and evaluation.

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS:
Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.
Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.
Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.
Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-25 pounds, operation of a motor vehicle.
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP

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