Regulatory and Accreditation Specialist - Performance Improvement
About City of Hope,
City of Hope's mission is to make hope a reality for all touched by cancer and diabetes. Founded in 1913, City of Hope has grown into one of the largest and most advanced cancer research and treatment organizations in the U.S., and one of the leading research centers for diabetes and other life-threatening illnesses. City of Hope research has been the basis for numerous breakthrough cancer medicines, as well as human synthetic insulin and monoclonal antibodies. With an independent, National Cancer Institute-designated comprehensive cancer center that is ranked top 5 in the nation for cancer care by U.S. News & World Report at its core, City of Hope's uniquely integrated model spans cancer care, research and development, academics and training, and a broad philanthropy program that powers its work. City of Hope's growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and cancer treatment centers and outpatient facilities in the Atlanta, Chicago and Phoenix areas.

The successful candidate:

** This position is open only to local candidates due to onsite requirements

Location: Zion, IL

Schedule

• Mon - Fri, Day shift (40 hrs per week)

Job Summary

The Regulatory and Accreditation team member leads the strategic development, coordination, and execution of regulatory compliance (CMS/IDPH), accreditation (Joint Commission), and other certifications (QOPI) activities across the Hospital organization. This role ensures City of Hope meets or exceeds hospital requirements set forth by federal and state regulatory bodies, national accrediting organizations, and internal policies to support compliance and deliver high-quality hospital-based patient care.

This position supports hospital performance and quality improvement initiatives by defining project scope, developing and monitoring timelines, and documenting outcomes to meet accreditation, regulatory, and quality standards.

The role manages small-scale hospital quality and safety patient projects from concept through implementation, assists in developing communication materials related to quality and regulatory initiatives (e.g., memos, newsletters, SharePoint or intranet content), and participates in larger, more complex projects as needed. Responsibilities include preparing internal and external reports by gathering, analyzing, and summarizing data for leadership and stakeholders, as well as managing and archiving all quality-related project documentation.

The Regulatory and Accreditation team member partners closely with clinical, administrative, legal, and quality teams to interpret evolving hospital regulations, support hospital survey and inspection readiness (Joint Commission/CMS), and drive continuous improvement in compliance systems. This role supports enterprise-wide initiatives and collaborates with leadership, departments, clinics, physicians, and administrative teams to promote regulatory excellence. Cross-coverage within the Quality team is required as needed.

This is a hospital-based position that requires onsite presence.

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

Education

• 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 that fosters 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.

City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location.