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Providence Health & Services Regulatory Accreditation Program Manager South Bay Community Service in Torrance, California


Providence is calling a Regulatory Accreditation Program Manager South Bay Community Service (Full time/Variable shift) at Providence Little Company of Mary Medical Center Torrance in Torrance, CA.

We are seeking a Regulatory Accreditation Program Manager South Bay Community Service who will function as support for the South Bay Community for compliance with accreditation standards, and state and federal regulations. Under the general supervision of the South Bay Executive Director, Quality, Risk & Safety, the position manages functions to prepare the South Bay Community continuum to meet external standards for accreditation, state and federal regulations.

The South Bay Community consists of two general acute care hospitals, two post-acute skilled nursing facilities, acute rehab, acute and outpatient psych, chemical dependency recovery and several affiliated off-site locations. The Regulatory Program Manager may be primarily located at one of the acute ministries within the South Bay (San Pedro or Torrance) but will be expected to work throughout the continuum of the South Bay Community

The Manager is responsible to collaborate with the South Bay Community Quality, Risk and safety leaders/specialists to ensure compliance with accreditation standards, and state and federal regulations. The Manager will assist these areas in analyzing clinical processes, identify potential risks for patients and develop strategies to maximize safety, effectiveness and efficiency.

In this position you will:

  • Coordinate regulatory survey preparation and the facility survey process (pre-survey, during survey and post-survey) for the following, but not limited to, surveys:

  • CMS annual skilled nursing survey

  • CDPH General Acute Care Hospital Survey (GACH) which will include MERP, and Patient Safety Licensing Survey

  • CDPH & LA County survey visits (radiological health, hazardous materials, laboratory, etc.)

  • LA County specialized certifications (EDAP, SRC, TCS, etc.)

  • Joint Commission HACP, Pulmonary Lab and miscellaneous chamaertification Surveys (Stroke, Home Health, Palliative Care)

  • CMS and FDA surveys/investigations

  • Other governmental and accrediting body surveys

  • In collaboration with the Executive Director and risk management may assist and lead complaint and/or at-cause investigations with regulatory and accrediting agencies

  • Monitor changes in external standards; advocates for changes in standards and regulations, and coordinate the South Bay Community’s continuum preparations to meet new standards

  • Work collaboratively across the South Bay continuum to support compliance with standards, state and federal regulations and survey preparation

  • Provide planned education sessions to all levels of the organization on regulatory and licensure compliance

  • Prepare for surveys and inspections related to all regulatory agencies

  • Maintain the South Bay continuum minutes, action plans, and accreditation documents

  • Develop and maintain methods to share information across the South Bay continuum about standards, common issues and effective practices to meet standards, e.g., conference calls, web site, bulletin boards

  • In conjunction with the Executive Director, partners with Medical Staff leadership, Medical Staff Office, and Administration to provide education to the Medical Staff on changes/new standards and regulations

  • Facilitate development of systems and process to track action items related to regulatory compliance

  • Coordinate the activities of The Joint Commission Function Teams

  • Assist the department managers and organization leaders in compliance with new and revised standards

  • Facilitate development of comprehensive Joint Commission action item updates that are reported to the appropriate quality committee/council

  • Update organization-wide policies and procedures in accordance with changes in accreditation standards, laws and/or applicable regulatory agencies

  • Other duties as assigned


Required qualifications:

  • 3 years experience in an acute care facility

  • 2 years working with accreditation standards, and state and federal regulations

  • Demonstrates a working knowledge of The Joint Commission standards and regulatory related requirements, federal and state laws and regulations

  • Demonstrates working knowledge of the hospital and ambulatory information systems and other computer based communication and data base systems

  • Skills:

  • Integrate effectively across various healthcare settings

  • Work efficiently and effectively in a matrix structured environment

  • Excellent verbal and written communication skills

  • Excellent problem solving skills

  • Quality and Safety

  • Driving improvement

  • Patient Experience

  • Risk Assessment

  • Change agent with positive approaches

  • Strong ability to lead and facilitate multi-disciplinary groups, develop effective teams

  • Prioritize and organize work in an accurate and timely manner

  • Process information and adapt quickly to a changing healthcare environment

  • Conduct multiple projects simultaneously

  • Promote a culture of transparency and openly discuss situations to be used as learning

  • Meet strict deadlines

  • Interact with regulatory officials, physicians, patients, and hospital personnel

  • Maintain good relations both inter and intra-departmentally

Preferred qualifications:

  • Bachelor's Degree in Nursing or Healthcare related field

  • Current California Registered Nurse License, or equivalent or higher level licensure

  • Healthcare Accreditation Certified Professional (HACP) and/or Certified Joint Commission Professional (CJCP)

  • CPHQ (Certified Professional in Healthcare Quality)

About the ministry you will serve:

Providence Little Company of Mary Medical Center Torrance is a 436-bed non-profit hospital that has served the greater South Bay communities of Los Angeles since 1960. We have a reputation for clinical excellence and sophisticated technology while providing care with a personal, healing touch. In addition to the finest general medical, surgical and critical care services, we offer a number of specialty programs including Cardiovascular Services, Women’s and Children’s Health, Oncology, and Emergency Care. We are proud to be named one of the Top 50 U.S. Hospitals for Heart Care by Thomson Reuters, the only community hospital in California to receive this honor. We were one of five hospitals in the United States recognized by American Hospital Association-McKesson for leadership and innovation in quality improvement. We received The Choice Award by AAHCP for Outstanding Customer Service Delivery, and were one of 24 hospitals and health systems in the nation to receive the Premier Award for Quality by the Premier healthcare alliance. As a member of Providence Health & Services, a Catholic-sponsored healthcare ministry, we believe strongly in respecting the dignity of each person, and give special concern to the most vulnerable members of our community.

For information on our comprehensive range of benefits, visit:

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Variable

Job Category: Non-Clinical Lead/Supervisor/Manager

Location: California-Torrance

Req ID: 266556