campaign-Day company_name-Accreditation,-Regulatory,-&-Licensing-(AR&L) hours_per_week-40 industry-NUE-SCAL-01|NUE|Non-Union-Employee is_manager-SCAL-Jobs job_level-Individual-Contributor job_status-Regular job_type-Standard salary_relocation-Full-time travel-Yes,-20-%-of-the-Time 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custom_fields.ReqID-1418059 custom_fields.Shift-Day custom_fields.Field1-Quality-&-Safety custom_fields.Field2-Mon,-Tue,-Wed,-Thu,-Fri custom_fields.Reindex-2 custom_fields.Facility-Fontana-Medical-Center custom_fields.MHSTheme-No custom_fields.PayBasis-Yearly custom_fields.PayRange-$131300---$169840-/-year 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custom_fields.core_ksa_2-<div><strong>Knowledge,-Skills-and-Abilities:-(Core)</strong></div><ul-style=columns:2;><li>Ambiguity/Uncertainty-Management</li><li>Attention-to-Detail</li><li>Business-Knowledge</li><li>Communication</li><li>Critical-Thinking</li><li>Cross-Group-Collaboration</li><li>Decision-Making</li><li>Dependability</li><li>Diversity,-Equity,-and-Inclusion-Support</li><li>Drives-Results</li><li>Facilitation-Skills</li><li>Health-Care-Industry</li><li>Influencing-Others</li><li>Integrity</li><li>Learning-Agility</li><li>Organizational-Savvy</li><li>Problem-Solving</li><li>Short--and-Long-term-Learning-&-Recall</li><li>Teamwork</li><li>Topic-Specific-Communication</li></ul> custom_fields.jobtitleLI-Accreditation,-Regulatory,-and-Licensing-Specialist-V-(KFHP/H)---1418059 custom_fields.leadership-no custom_fields.CFSalaryLow-131300 custom_fields.HawaiiTheme-Quality-&-Safety custom_fields.JobSchedule-Full-time 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custom_fields.functional_ksa_2-<div><strong>Knowledge,-Skills-and-Abilities:-(Functional)</strong></div><ul-style=columns:2;><li>Consulting</li><li>Credentialing-Database-Systems</li><li>Delegation</li><li>Evidence-Based-Medicine-Principles</li><li>Health-Care-Data-Analytics</li><li>Health-Care-Policy</li><li>Health-Care-Quality-Standards</li><li>Managing-Diverse-Relationships</li><li>Project-Management</li><li>Quality-Assurance-Process</li><li>Risk-Assessment</li></ul> custom_fields.WorkingHoursStart-08:00-AM custom_fields.PrefQualification1-<div>-<b>Minimum-Qualifications:</b></div>-<br/><ul-style='margin-top:-0;margin-left:-1px;margin-bottom:-0;'><li>Minimum-three-(3)-years-of-experience-in-a-leadership-role-with-or-without-direct-reports.</li><br/><li>Minimum-three-(3)-years-of-experience-with-databases-and-spreadsheets.</li><br/><li>Bachelors-degree-in-Business-Administration,-Health-Care-Administration,-Nursing,-Public-Health,-or-related-field-AND-minimum-seven-(7)-years-of-experience-in-health-care-operations,-quality,-risk-management,-hospital-environment,-or-a-directly-related-field-OR-minimum-ten-(10)-years-of-experience-in-health-care-operations,-quality,-risk-management,-hospital-environment,-or-a-directly-related-field.</li></ul><br/><div><strong>Preferred-Qualifications:</strong></div><ul-style=margin-bottom:0;margin-left:1px;margin-top:0;><li>Three-(3)-years-of-National-Committee-of-Quality-Assurance-(NCQA)-or-related-survey-experience.</li><li>Master's-degree-in-Business-Administration,-Health-Care-Administration,-Nursing,-Public-Health,-or-related-field.</li></ul> custom_fields.CaliforniaLocations-SCAL custom_fields.LocationDescription-California,Fontana,Fontana-Medical-Center custom_fields.NurseResidencyTheme-Quality-&-Safety custom_fields.VisionServicesTheme-Quality-&-Safety custom_fields.ExternalReferenceCode-1418059 custom_fields.InternalReferralTheme-Quality-&-Safety custom_fields.PhysicianAssistantTheme-Quality-&-Safety custom_fields.CFIsSignOnBonusAvailable-No custom_fields.FacilityServicesandMaterialsManagementTheme-Quality-&-Safety

Accreditation, Regulatory, and Licensing Specialist V (KFHP/H)

Primary Location Fontana, California Facility Name Fontana Medical Center Schedule Full-time Shift Day Salary $131300 - $169840 / year

Job Number 1418059 Date Posted 04/06/2026

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Job Summary:

Conducts regulatory audits and surveys by consulting on the interpretation and interaction of current regulatory policies and requirements in preparation for surveys. Organizes, coordinates, and conducts facilitation of on-site visits and evaluations. Performs site visits in accordance with criteria to ensure survey readiness. Ensures completion of surveys, independently. Conducts routine audits and mock surveys to aid in preparedness, tracking, trending, and facilitation of corrective action plans. Collaborates with others to complete annual reporting. Ensures licensing and accreditation by reviewing requirements for new, expanding, and existing facilities/services in relation to relevant accrediting standards, evaluating relevant risk and impact independently. Consults with departments to ensure certification and conducts complex gap analyses. Serves as the subject matter expert by maintaining and facilitating awareness of internal policies and consulting on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation. Develops complex content and delivers education programs to align policies with regulatory requirements. Conducts data management by entering and analyzing complex practitioner/provider data. Independently reviews, drafts, and provides consultative expertise on implementation of action plans for timely implementation.

Essential Responsibilities:

Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.

Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.

Serves as the subject matter expert for regulations projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees and projects to drive development of policies or procedures for regulations and auditing processes; developing complex content and delivering tailored educational programs to align organizational policies and procedures with regulatory requirements; and anticipating and weighing practical/technical considerations in addressing issues and coordinating with the appropriate stakeholders to develop resolutions.

Develops data management and reporting processes by: entering complex practitioner/provider data and conducts data cleaning as needed; and entering, analyzing, and independently drafting and reviewing action plans/recommendations required data into appropriate databases.

Ensures licensing and accreditation by: independently reviewing and guiding others to review requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for complex cases; and independently conducting a widely impactful and detailed gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.

Identifies and recommends improvements to processes of responding to regulatory audits and survey preparedness efforts by: independently enacting complex reporting, keeping current on regulatory requirements, and guiding others to do the same in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); serving as liaison between external evaluators, vendors, and senior stakeholders to facilitate on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness; delivering requested complex audit documentation, information, and reports; assessing the workflow of auditing surveys to identify gaps in completion and reporting, focusing on high vulnerability areas; facilitating educational forums, conducting routine audits, and leading mock surveys within departments to ensure auditing and survey preparedness tracking, trending, and facilitating the development of high impact corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and leading the collaborations with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.

Knowledge, Skills and Abilities: (Core)

Ambiguity/Uncertainty Management
Attention to Detail
Business Knowledge
Communication
Critical Thinking
Cross-Group Collaboration
Decision Making
Dependability
Diversity, Equity, and Inclusion Support
Drives Results
Facilitation Skills
Health Care Industry
Influencing Others
Integrity
Learning Agility
Organizational Savvy
Problem Solving
Short- and Long-term Learning & Recall
Teamwork
Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

Consulting
Credentialing Database Systems
Delegation
Evidence-Based Medicine Principles
Health Care Data Analytics
Health Care Policy
Health Care Quality Standards
Managing Diverse Relationships
Project Management
Quality Assurance Process
Risk Assessment

Minimum Qualifications:

Minimum three (3) years of experience in a leadership role with or without direct reports.

Minimum three (3) years of experience with databases and spreadsheets.

Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum seven (7) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum ten (10) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field.

Preferred Qualifications:

Three (3) years of National Committee of Quality Assurance (NCQA) or related survey experience.
Master's degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field.

Primary Location: California,Fontana,Fontana Medical Center Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Worker Location: Onsite Employee Status: Regular Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Fontana Medical Center - New - Hosp Adm-Survey Accredita Prep - 0801 Pay Range: $131300 - $169840 / year Kaiser Permanente is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills and geographic location along with a review of current employees in similar roles to ensure that pay equity is achieved and maintained across Kaiser Permanente. Travel: Yes, 20 % of the Time On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

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Expected Employee Conduct >