What are the responsibilities and job description for the Regulatory Affairs, Accreditation & Licensing Analyst position at St. Charles Health System?
The Regulatory Affairs, Accreditation & Licensing Analyst provides regulatory analysis, compliance evaluation, accreditation readiness, hospital licensing oversight, and document governance support across St. Charles Health System. Serving as a system-wide expert resource, this role interprets federal, state, licensing, and accreditation requirements and analyzes their operational impact across clinical and operational programs.
The Analyst performs regulatory gap analyses, tracers, and compliance assessments related to Joint Commission, CMS Conditions of Participation, Oregon Health Authority, OSHA, and other applicable regulatory agencies. This position develops data-informed recommendations to support organizational regulatory strategy, accreditation readiness, staffing compliance, document governance, and ongoing regulatory compliance across the health system.
In addition, this role provides enterprise level regulatory and document governance analysis to support accreditation readiness, regulatory compliance, and organizational risk mitigation. The Analyst maintains and coordinates document governance processes, monitors compliance with regulatory and accreditation requirements, and delivers executive-level reporting and consultation to ensure the integrity, consistency, and ongoing effectiveness of organizational policies and controlled documents.
This position does not directly supervise caregivers but collaborates with leaders across the health system to support regulatory compliance, accreditation readiness, hospital licensing, document governance, and organizational risk reduction.
Essential Functions And Duties
Analyzes and evaluates accreditation, licensing, and regulatory compliance activities to identify risks, compliance gaps, and opportunities for improvement. Interprets applicable regulations and accreditation standards and advises leaders on operational impact, regulatory obligations, and survey readiness.
Conducts enterprise-wide regulatory and accreditation readiness assessments, tracers, audits, and compliance reviews to evaluate adherence to federal, state, and accrediting body requirements and identify opportunities for improvement.
Analyzes survey findings, corrective actions, compliance metrics, and organizational performance indicators to identify trends, assess regulatory risk, and develop recommendations that support continuous readiness and sustained compliance.
Coordinates regulatory reporting, Joint Commission submissions, licensure documentation, and survey-related follow-up activities while interpreting regulatory requirements and communicating implications to operational and organizational leaders. Partners with leadership to support the development and ongoing maturation of the organization's regulatory readiness program.
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.
Provides comprehensive oversight and management of hospital-based licensing activities to ensure ongoing compliance with federal, state, and accrediting agency requirements. Coordinates and maintains hospital licenses across all licensed hospital locations while ensuring regulatory requirements are met for existing operations and new service expansions.
Provides regulatory oversight for hospital-based construction, renovation, and space modification projects in collaboration with Facilities, Planning, Construction and Design, and other system partners. Reviews and coordinates licensure applications, inspections, and approvals in accordance with OHA, OSHA, FGI, and CMS requirements.
Provides enterprise-level oversight and governance of the health system's document management program, ensuring the integrity, accuracy, accessibility, and regulatory compliance of controlled clinical and corporate documents. Analyzes and monitors document governance processes, regulatory requirements, and review cycles to ensure policies and organizational documents remain current, compliant, and aligned with accreditation, licensure, and operational standards.
Serves as the primary resource for document governance matters at the executive level, regularly reporting program performance, compliance status, and governance priorities to senior leadership and organizational committees while facilitating policy review and approval processes. Provides strategic consultation to document owners, leadership, and governance bodies regarding regulatory requirements, document content, and organizational risk, supporting enterprise-wide consistency, accreditation readiness, and sustained regulatory compliance.
Exercises independent judgement in analyzing regulatory requirements and compliance data and provides recommendations that influence operational and leadership decision making.
Supports regulatory and quality committees, including agenda development, documentation, and follow-up. Makes expert recommendations on policy development, revision, and regulatory alignment. Supports Lean principles, continuous improvement, and a culture of safety.
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.
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, Health Accreditation Certification Program, FEMA Certificates for IS-100, IS-200, IS-700, IS-800 and/or additional advanced accreditation, quality, or compliance certifications.
Experience
Required: Minimum five (5) 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.
The Analyst performs regulatory gap analyses, tracers, and compliance assessments related to Joint Commission, CMS Conditions of Participation, Oregon Health Authority, OSHA, and other applicable regulatory agencies. This position develops data-informed recommendations to support organizational regulatory strategy, accreditation readiness, staffing compliance, document governance, and ongoing regulatory compliance across the health system.
In addition, this role provides enterprise level regulatory and document governance analysis to support accreditation readiness, regulatory compliance, and organizational risk mitigation. The Analyst maintains and coordinates document governance processes, monitors compliance with regulatory and accreditation requirements, and delivers executive-level reporting and consultation to ensure the integrity, consistency, and ongoing effectiveness of organizational policies and controlled documents.
This position does not directly supervise caregivers but collaborates with leaders across the health system to support regulatory compliance, accreditation readiness, hospital licensing, document governance, and organizational risk reduction.
Essential Functions And Duties
Analyzes and evaluates accreditation, licensing, and regulatory compliance activities to identify risks, compliance gaps, and opportunities for improvement. Interprets applicable regulations and accreditation standards and advises leaders on operational impact, regulatory obligations, and survey readiness.
Conducts enterprise-wide regulatory and accreditation readiness assessments, tracers, audits, and compliance reviews to evaluate adherence to federal, state, and accrediting body requirements and identify opportunities for improvement.
Analyzes survey findings, corrective actions, compliance metrics, and organizational performance indicators to identify trends, assess regulatory risk, and develop recommendations that support continuous readiness and sustained compliance.
Coordinates regulatory reporting, Joint Commission submissions, licensure documentation, and survey-related follow-up activities while interpreting regulatory requirements and communicating implications to operational and organizational leaders. Partners with leadership to support the development and ongoing maturation of the organization's regulatory readiness program.
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.
Provides comprehensive oversight and management of hospital-based licensing activities to ensure ongoing compliance with federal, state, and accrediting agency requirements. Coordinates and maintains hospital licenses across all licensed hospital locations while ensuring regulatory requirements are met for existing operations and new service expansions.
Provides regulatory oversight for hospital-based construction, renovation, and space modification projects in collaboration with Facilities, Planning, Construction and Design, and other system partners. Reviews and coordinates licensure applications, inspections, and approvals in accordance with OHA, OSHA, FGI, and CMS requirements.
Provides enterprise-level oversight and governance of the health system's document management program, ensuring the integrity, accuracy, accessibility, and regulatory compliance of controlled clinical and corporate documents. Analyzes and monitors document governance processes, regulatory requirements, and review cycles to ensure policies and organizational documents remain current, compliant, and aligned with accreditation, licensure, and operational standards.
Serves as the primary resource for document governance matters at the executive level, regularly reporting program performance, compliance status, and governance priorities to senior leadership and organizational committees while facilitating policy review and approval processes. Provides strategic consultation to document owners, leadership, and governance bodies regarding regulatory requirements, document content, and organizational risk, supporting enterprise-wide consistency, accreditation readiness, and sustained regulatory compliance.
Exercises independent judgement in analyzing regulatory requirements and compliance data and provides recommendations that influence operational and leadership decision making.
Supports regulatory and quality committees, including agenda development, documentation, and follow-up. Makes expert recommendations on policy development, revision, and regulatory alignment. Supports Lean principles, continuous improvement, and a culture of safety.
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.
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, Health Accreditation Certification Program, FEMA Certificates for IS-100, IS-200, IS-700, IS-800 and/or additional advanced accreditation, quality, or compliance certifications.
Experience
Required: Minimum five (5) 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.