Ambulatory Regulatory & Accreditation Program Manager - Jefferson Health Systems

Job Details

The Jefferson Health Systems Ambulatory Accreditation/Regulatory Program Manager manages the ambulatory clinic /physician based practices (PBP) (under the hospital licensure) throughout the Jefferson Health system to ensure compliance with state licensure regulations, CMS conditions of participations and Joint Commission standards. They will manage the enterprise ambulatory/outpatient regulatory and accreditation program, providing oversight, guidance and recommendations for the outpatient practice conversion to hospital based physician practices and for continual accreditation readiness.

The Senior Specialist collaborates with local hospital regulatory and leadership teams to manage survey readiness through education and rounding opportunities for outpatient practices that are under the Jefferson Hospital licensure.

Travel 2-3 days/week to physician practices is required. Primary regions include:
Philadelphia, Bucks and Montgomery County, PA, South Jersey, and to the Lehigh Valley region. Flexible hybrid work available on non-office days.

• Serves as the subject master expert for the Department of Health (DOH), Joint Commission and CMS regulations as they pertain to enterprise clinics/PBPs under hospital licensure.
• The Senior Specialist being highly skilled in the interpretation of the DOH regulations and accreditation standards, effectively communicates to local and enterprise leaders the organizational gaps identified and implements action plans to meet standards and/or close gaps. Oversees publicly reported outcomes or data and communicates trends or concerns with local/enterprise leaders. Ensures system failures are reported promptly and appropriately.
• Manages the communication of proposed and new regulations/standards/updates to clinics/PBPs and local leadership through structured meetings/emails and provides valuable input on methods to meet compliance.
• Delivers recommendations (written or verbal) on areas of non-compliance with FGI guidance and regulations during ambulatory practice site conversion assessments and discussions.
• Manages the PA DOH DAAC (or NJ equivalent) occupancy process for new equipment, services, and/or construction projects for the ambulatory/provider based practices. Established subject matter expert for state, federal or regulatory surveys for the PBP/ ambulatory clinics.
• Develops and manages the PBP rounding schedule, distributes findings and reviews the actions plans with the clinics/PBPs leadership teams. Assures timely resolution of observed issues and conflicts from the PBP rounds.
• Collaborates with hospital regulatory and PBP leaders, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplines.

• Bachelor’s Degree
• 4 years of healthcare accreditation and regulatory experience and
• Less than 1 year of previous experience converting outpatient clinics to hospital based practices
• Working expert knowledge of PADOH, NJDOH, CMS, FGI and TJC standards/guidelines.
• Capable of working independently
• Excels in solving problems before they become critical
• Work effectively with others
• Effectively handles competing priorities

• Master’s Degree
• 4 years Provided based practice experience

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use,
* patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer:
This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Workday Day (United States of America)

Regular

Thomas Jefferson University

1101 Market, Philadelphia, Pennsylvania, United States of America

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