Regulatory Affairs, Accreditation & Licensing Analyst

About this role

Pay range: $78,478 - $117,728 annually, based on experience.

About St. Charles Health System:

St. Charles Health System is a leading healthcare provider in Central Oregon, offering a comprehensive range of services to meet the needs of our community. We are committed to providing high-quality, compassionate care to all patients, regardless of their ability to pay. Our values of compassion, excellence, integrity, teamwork, and stewardship guide our work and shape our culture.

What We Offer:

Competitive Salary

Comprehensive benefits including Medical, Dental, Vision for you and your immediate family

403b with up to 6% match on Retirement Contributions

Generous Earned Time Off

Growth Opportunities within Healthcare

ST. CHARLES HEALTH SYSTEM JOB DESCRIPTION

TITLE:                                       Regulatory Affairs, Accreditation & Licensing Analyst REPORTS TO POSITION:         Manager, Regulatory Affairs, Accreditation & Safety DEPARTMENT:                          Quality Management DATE LAST REVIEWED:           July 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 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 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.

Provide

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