Regulatory Specialist

Position: Regulatory Specialist at Penn Medicine
** Description*
* Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

Supports the leaders and staff of the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which fall under HUP's Pennsylvania Department of Health (PA DOH) hospital license to ensure compliance with state licensure regulations, Centers for Medicare and Medicaid Services' (CMS) hospital conditions of participation and Joint Commission (JC) accreditation standards.

The Regulatory Specialist actively participates and leads the organization's efforts to prepare for, take part in, and respond to any necessary follow-up of both announced and unannounced regulatory body site visits and inquiries. Responsibilities also include informing staff regarding hospital accreditation standards and licensure regulations. Completes certain regulatory related applications, such as the PA DOH hospital questionnaire, JC applications, and the hospital license application.

Actively works with policy owners to provide updated regulatory standards and regulations to ensure Departmental, Administrative and Medical Board hospital policies reference and reflect the most current information. Provides regulatory consultation for internal customer projects to ensure that they are consistent with regulatory agency regulations. Develops, maintains and documents in requisite internal databases in order to track activities, meet document retention requirements, and ensure continuous process improvement and efficiency within the department.

Demonstrates understanding of concepts, methods, techniques, and principles needed to accomplish job responsibilities, such as PA DOH, JC, and CMS regulations.

Responsibilities:

Essential Accountabilities:

- Ensure internal clients are aware of services offered - Supports the vision of the UPHS Clinical Effectiveness and Quality Improvement Department - Develop relationships within the organization to ensure effective communication and partnership / cooperation in all facets of the licensure and accreditation process - Collaborate with leaders and staff to evaluate proposed rules / regulations and assess, develop, or participate in, as appropriate, regulatory advocacy approaches - Coordinate with others, as appropriate, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplines

Operations:

- Coordinates and participates in regulatory survey readiness activities - Ensures that initiatives are in compliance with accrediting, regulatory, and institutional standards - Maintains the confidentiality of all inter-departmental correspondence as well as the external clients - Primary liaison with state agency, including but not limited to PA DOH - Serves as a liaison with hospital departments, including Pharmacy, Infection Control, Radiology, Perioperative Services, Respiratory, etc, to offer consultation and work collaboratively to develop workable solutions to regulatory challenges - Standards Interpretation - Interpretation of PA DOH, CMS (hospital), and TJC regulations/standards.

This includes subject matter expertise, partnering with TJC/CMS Chapter Leads, departments, units, and practices to apply regulations to existing operation while staying within institutional policy(ies) (workable solutions).

Survey Readiness Materials & Communications - Develop survey readiness materials for accreditation, certification and other types of surveys which include templates & content for effective & consistent communication of accreditation, licensure, & certification…