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Regulatory and Accreditation Consultant - Regulatory Compliance

Benefits Eligibility (Employment Type):  Full-time benefits (32-40 hours per week)
Shift Type:  Day
Shift Length:  Variable
Primary Location (City):  Vancouver
State:  WA

PeaceHealth is seeking a Regulatory and Accreditation Consultant - Regulatory Compliance for a 1.0 full time equivalent Exempt position. This position will be working Day shift with shift durations of Variable.

Req ID: 175264



Supports leadership and system/network/community/medical group in the creation and implementation of policies, procedures, processes and programs designed to meet regulatory and accreditation requirements. In collaboration with the Director and operational leaders, implements and monitors a standard quality management structure and assists with internal auditing and coaching of managers and front line staff in regard to regulatory compliance. Works with other disciplines and regulatory departments to coordinate compliance efforts across the PeaceHealth system.   Serves the organization to promote operational standardization by maintaining one interpretation throughout PeaceHealth as it applies to rules and regulations monitored by this department. 




  1. Assists medical group/hospital/provider based entities with regulatory surveys: state, federal, accreditation, fire, investigatory, etc. and supports the provision of reports back to local regulatory and system regulatory resources of these activities. Assists with monitoring of regulatory changes, and provides regular reports and updates to appropriate network and community leadership/teams.
  2. Collaborates with appropriate administrative, clinical and operational leaders to develop and implement a strategy for regulatory and accreditation compliance, specific to that facility, but aligned with the other facilities within PeaceHealth.  Assists in promoting the use of a standard quality management manual and plan which guides how quality and regulatory compliance is integrated into our business operations
  3. Facilitates creation of community regulatory expertise that serves the hospital/clinic to promote operational compliance to enhance performance through the use of standard tools and approaches, consistent interpretation of rules and regulations, standardization of process/practice, and outcomes management. Works to strengthen integration and cohesiveness between facilities, providers and care settings.
  4. Supports operational leadership at the network /facility/clinic level in the creation and implementation of policies, procedures, processes and programs designed to meet regulatory and accreditation requirements.
  5. Maintains current knowledge and awareness of state, federal, and other rules and regulations that apply to clinical settings associated with PeaceHealth including CMS Conditions of Participation and appropriate Accreditation Standards.  Supports implementations using PeaceHealth’s standard process improvement methodologies
  6. Participates in development of processes/systems designed to share and recognize performance improvements and regulatory compliance across the organization to meet rules and regulations.  Provides opportunities for collaboration that lead to system standardization
  7. Support network/community/PHMG teams related to system-wide approaches for regulatory and accreditation issues/processes.  Supports skills and competency development in knowledge and execution of regulatory and accreditation requirements in team of related community-based resources.  With system team, designs training curriculum, develop program content and provide education to leadership teams, quality leaders, supervisors and staff regarding regulatory and accreditation requirements.
  8. Provides network and facility leadership with progress reports (including recommendations), as needed.  Supports tracking and trending of compliance data, identifies opportunities for improvement.
  9. Ensures that responsibilities are performed consistent with the deliberate plans of the organization; maintains a sensitive, caring and safe environment for customers, employees, and others; and operates within the limits of approved budgets.
  10. Performs other duties as assigned


QUALIFICATIONS Required unless otherwise stated


  • Bachelor’s degree required, preferably in a healthcare-related field. 
  • RN or other clinical background preferred.  Expert knowledge and skills obtained through a combination of education, training and experience. 



  • Minimum five years related experience in a healthcare setting; preferably hospital, clinic, or health system- related.
  • Proven success in supporting healthcare institutions in meeting regulatory requirements and successfully reaching accreditation.
  • Advanced knowledge of state, federal, and accreditation requirements including but not limited to: CMS Conditions of Participation for acute care and critical access hospitals, provider based entities, ISO 9001, NIAHO, State healthcare rules and statutes, and state licensing requirements. General knowledge in other regulatory areas such as FDA and OSHA.
  • Strong knowledge and experience in quality improvement principles
  • Experience with managing complex programs and projects, specifically with a focus on regulatory and accreditation requirements and demonstrated successful completion of quality improvement projects with desired outcomes.
  • Proven skills in team facilitation, project implementation, effective data interpretation, customer relations 
  • Experience and knowledge in use of administrative data quality, data specifications and statistical validity.
  • Experience using, teaching and applying quality management tools



  • RN preferred



  • Excellent verbal and written communication skills
  • Ability to prioritize and manage multiple projects




  • Work requires fairly light physical exertion from up to 65% of the time.    
  • Ability to lift objects weighing 30 lbs. or less.          
  • Work is performed under normal working conditions with adequate lighting and ventilation.        
  • Job duties frequently require intense concentration and attention to detail (up to 65% of work time).


Please apply online to be considered. For full consideration of your skills and abilities, please attach a current resume with your application.


About PeaceHealth


PeaceHealth, based in Vancouver, Wash., is a not-for-profit Catholic health system offering care to communities in Washington, Oregon, and Alaska. PeaceHealth has approximately 16,000 caregivers, a multi-specialty medical group practice with more than 900 providers and 10 medical centers serving both urban and rural communities throughout the Northwest. In 1890, the Sisters of St. Joseph of Peace founded what has become PeaceHealth. Today, PeaceHealth is the legacy of its founding Sisters and continues with a spirit of respect, stewardship, collaboration and social justice in fulfilling its Mission. 


We offer competitive compensation, a robust benefits package and a collaborative, Mission-driven work environment! To learn more about working at PeaceHealth and the Vancouver community please visit our homepage: www.peacehealth.org/careers.


Get a feeling for the Spirit of PeaceHealth through this three-minute video, and visit us on Facebook or LinkedIn!


Questions? Review our Employment FAQ or email Recruitment@peacehealth.org. Please note this email does not accept resumes or applications.


Location: Vancouver, Southwest Medical Center (150)
Job Category:  Business, Administrative & Facilities 
Shift:  Day
Shift Length: Variable
FTE: 1.0
Work Type:  Full Time
Hourly compensation starts at: $36.26, more depending on experience
Required Certifications/Licensure: 


PeaceHealth is committed to providing equal employment opportunities to all qualified job applicants and employees without regard to the following statuses: protected veteran; qualified individual with a disability; race; ethnicity; religion; gender; pregnancy; gender identity; national origin; age; genetic information; sexual orientation; or any other protected status in accordance with local, state, or federal laws.


The above information is intended to indicate the general nature and level of work performed by this position. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.


Posting Notes: Vancouver || Business, Administrative & Facilities || Risk Management & Quality || Full Time || ORG INTEGRITY

Nearest Major Market: Portland Oregon
Nearest Secondary Market: Tacoma

Job Segment: Regulatory Affairs, Consultant, Consulting, Compliance, Medical, Legal, Contract, Healthcare