Program Manager, Regulatory and Accreditation

Hourly Pay Range: $46.79 - $72.52 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

• Position:
  Program Manager, Regulatory/Accreditation
• Location:
  
  Glenview, IL
• Full Time: 40 hours/week
• Hours:
  
  Monday-Friday, 8:00a-4:30p
• Required Travel:
  To other Endeavor locations

Reporting to the Assistant Vice President Accreditation, Regulatory and Compliance, coordinates and serves as primary contact for system wide complex accreditation, certification and regulatory activities, including review of abuse allegations, survey preparation and readiness assessments for facilities within Endeavor Health.

Lead and support entity/business line compliance with The Joint Commission (TJC), the Accreditation Commission for Health Care (ACHC), Accreditation Association for Ambulatory Health Care (AAAHC), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid Services (CMS) and other State and Federal agencies.

• Lead preparation for regulatory activities at assigned entities, departments, business line and/or institutes. Work collaboratively with content area experts in the organization to ensure a continuous state of readiness throughout the organization.
• Develop, in collaboration with assigned entities, departments, business line and/or institutes senior and executive leader on compliance strategies and tactics.
• Provide oversight to required entity regulatory reporting in conjunction with quality and other departments.
• Lead assigned entities' development and monitoring of responses to the Joint Commission and IDPH related to Evidence of Standards Completion (ESC) or other post survey activity.
• Assist system accreditation and regulatory activities, including survey preparation and readiness assessments.
• Assist with interpretation of standards and regulations, and serves as secondary point of contact for accreditation bodies.
• Assist AVP in providing education for the organization leaders regarding regulatory and accreditation issues. Identifies learning needs and opportunities and researches training content and methods in collaboration with key areas impacted.
• Responsible for monitoring regulatory websites for new information and new or revised standards, collaboratively evaluating compliance towards those changes and is instrumental in the development, assessment and achievement of organization readiness.
• Lead readiness efforts at assigned entities, departments and/or institutes.
• Lead standardization or regulatory workflows associated with assigned system policy and departments (eg clinical contract reviews, supply chain, HIM, etc.).
• Co‑lead abuse and key sentinel investigations with local or system leaders, ensure standardization of investigation. Documentation and follow‑up. Analyze trends and recommend opportunities for improvement.
• Manage oversight of Tracer & Epic audit reports to support monitoring and reporting of regulatory compliance risk.
• Support Policy Stat workflows at assigned entities, departments, and/or institutes.
• Support regulatory audit and reviews to ensure compliance with provider based rules, co‑location rules, ADA and other regulatory requirements.
• Other duties as assigned.

• Bachelors Degree Required
• 5+ Years 5 Years experience in a clinical setting.
• 3 Years 3 Years experience in quality, risk management, or regulatory/accreditation role.
• Knowledge:
  Familiarity with TJC, CoP, IDPH, EPIC and hospital clinical and operational workflows, and admin functions. Commitment to staying current with evolving regulations, standard and best practices in healthcare.
• Skills:
  
  Excellent written and presentation skills. Managing accreditation/change projects,…