Regulatory Affairs, Accreditation and Licensing Specialist

Regulatory Affairs, Accreditation & Licensing Specialist

Pay range: $34.95 - $52.41

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…