Sutter Health Manager - Accreditation and Licensure in Modesto, California


Serving the greater Stanislaus County with 423 plus acute care beds, Memorial Medical Center provides a full continuum of care including 24-hour emergency care, inpatient and outpatient surgery, obstetrics, pediatrics, nuclear medicine, dialysis therapy, diagnostic imaging, intensive care, physical therapy, and home health. Specialized care includes Memorial Regional Cancer Center and Memorial Heart Institute.

The Manager of Accreditation & Licensure is responsible and accountable to develop and coordinate components of the Memorial Medical Center's Performance Improvement (PI) Program and ensure MMC 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 and training and 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.


Minimum Requirements:

  • Bachelor's degree in a healthcare related field

  • A minimum of 3 years recent experience in healthcare outcomes and performance improvement initiatives and/or experience in licensing/accreditation compliance and survey preparation.

  • Experience in leading safety/quality/clinical effectiveness initiatives.

  • Driver license, valid in the state of California

  • Must be able to travel in and out of Stanislaus County, including transcontinental travel.

Preferred Requirements:

  • Bachelor's degree in nursing (BSN)

  • Registered Nurse with a California state licensure upon hire

  • Master's degree in a healthcare related field

  • Certified Professional Healthcare Quality RN (CN-PH QUAL)

  • Lean Certified

Skills & Knowledge :



Must demonstrate excellent written/verbal interpersonal communication and problem solving skills. Data analytics acumen.


Ability to manage own time and schedule own tasks. Must have initiative to work effectively without constant supervision and direction.


Demonstrated proficiency in Microsoft Office Suite, including Work, Power Point, and Excel is required. Ability to format tables, retrieve data via queries, and create presentations via Power Point.


Must be able to travel in and out of the Stanislaus County, including transcontinental travel. If MMC and/or own vehicle is used on corporate business, must possess valid California driver’s license and upon request, provide proof of liability insurance.


Ability to communicate effectively with a wide variety of personalities and departments, including medical staff members.


Ability to troubleshoot and provide direction under state laws


Primary Location: California, Central Valley, Modesto

Organization: Memorial Medical Center, Modesto

Employee Status: Regular

Benefits: Yes

Position Status: Exempt

Union: No

Job Shift: Day

Shift Hours: 8 Hour Shift

Days of the Week Scheduled: Monday-Friday

Weekend Requirements: Other

Schedule: Full Time

Hrs Per 2wk Pay Period: 80

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.