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Manager, Accreditation & Licensure

Job ID R-2605 Date Posted 01/04/2023 Location Burlingame, California Schedule/Shift/Weekly Hours Regular/Days/40


MPHS-Mills-Peninsula Medical Center

Position Overview:

Responsible and accountable to develop and coordinate components of Performance Improvement programs and ensure affiliate is in compliance with the Joint Commission accreditation standards, state and federal regulations and other identified standards. The responsibility/accountability includes resource management, regulatory compliance and participation in quality improvement activities. To facilitate improvement activities utilizing PI methodologies, and to serve as a resource to assist and train others on performance improvement methodologies and evidence-based patient safety and quality initiatives. To coordinate activities related to licensing and accreditation compliance and continuous survey readiness. The position provides guidance, team facilitation, training &support for performance improvement and special projects within the organization. Act as the primary point of contact for affiliates' survey readiness improvement needs and facilitates communications appropriately.

Job Description:


Equivalent experience will be accepted in lieu of the required degree or diploma.

Bachelor's: Management, public health, nursing, business administration, organizational leadership or related field. or equivalent education/experience


8 years progressively responsible experience in patient safety / quality/performance improvement clinical or educational environment.

8 years recent experience in healthcare outcomes and performance improvement initiatives and/or experience in licensing/accreditation compliance and survey preparation.

8 years experience in leading safety/quality/clinical effectiveness initiatives.


Operations, leadership, critical thinking, analysis, teaching, facilitation, coaching, mentoring and project management skills required.

Knowledge of population health management practices, policy, programs, initiatives and functions.

Ability to train staff in various quality improvement and performance improvement methodologies.

Exemplary written and oral communication skills; to include presentations and comprehensive analysis reporting on performance improvement issues.

Ability to partner and collaborate with physician leadership and work effectively with providers and physician site leadership.

Ability to analyze problems, to reach practical conclusions, and institute effective changes.

Ability to evaluate the performance of staff, identify behavior and performance problems, and staff development needs, and take appropriate actions as necessary.

Advanced computer skills in Microsoft Office: [Word, Excel, Outlook and PowerPoint] EPIC, Midas.

Ability to implement department policies and procedures and ensure adherence.

Must have organizational skills and the ability to balance numerous priorities at the same time, be detail-oriented, self-directed and able to work with minimal supervision.

Customer service skills.

Ability to compile, organize, summarize, prepare in text or graphic form and proofread extensive spreadsheets and data from a variety of sources.

Ability to write executive summaries.

Must be able to deal appropriately with confidential and sensitive information and to demonstrate diplomacy, tact and a high level of professionalism.

Organizational skills, ability to work on multiple projects under multiple deadlines; must be highly energetic, and able to embrace challenges and change.

Must be a team player and work well with a variety of people in all levels of the organization

Experience leading safety/quality/clinical effectiveness initiatives with high level of independence.

Experience in successfully facilitating collaborative, cross-functional projects, including the ability to define program project or process objective, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological, and fiscal resources to accomplish goals and objectives in a resourceful and timely manner.

An in-depth knowledge of regulations and guidelines for governing areas of responsibility.

Pay Range: $57.94-$86.91

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

Job Shift:



Full Time

Shift Hours:


Days of the Week:

Friday, Monday, Thursday, Tuesday, Wednesday

Weekend Requirements:






Position Status:


Weekly Hours:


Employee Status:


Number of Openings:


Sutter Health Affiliates are equal opportunity employers EOE/M/F/Disability/Veterans.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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