Accreditation and Licensure Specialist - Ephrata - Day

Wellspan Health - Ephrata, PA

Full-time - Entry Level

Ephrata, PA

Ambulatory Health Care Services

About the position

The Accreditation and Licensure Specialist at WellSpan Health is responsible for ensuring compliance with various regulatory standards and accreditation requirements for both inpatient and outpatient hospital entities. This role involves conducting audits, analyzing data, and facilitating improvements in compliance processes. The specialist will also serve as a backup for on-site surveys and work collaboratively with leadership to enhance regulatory compliance and best practices across the organization.

Responsibilities

• Ensures compliance with Federal/State/Accreditation Standards related to licensure.
• Coordinates survey follow-up activities, including plans of action and monitoring systems.
• Schedules and coordinates survey-related activities such as agendas and site visits.
• Educates staff on standards interpretation and assists in planning compliance improvements.
• Manages mock tracers for off-site locations, analyzes data, and develops action plans.
• Performs structured monthly audits of medical records for completeness and accuracy.
• Compiles data and prepares reports following regulatory surveys.
• Analyzes data for trends and presents findings to leadership.
• Evaluates procedures and provides tools for sustained improvement.
• Develops and implements corrective action plans for survey findings.
• Stays updated on regulatory agency requirements related to accreditation.
• Utilizes tracer findings to initiate improvements and educate staff.
• Provides updates on compliance issues to the Director.
• Develops networking relationships for regulatory compliance activities.
• Serves as a backup to the Director in their absence.
• Participates as a key member of the Environment of Care team.

Requirements

• Associates Degree required; Bachelor's Degree preferred.
• 1 year of experience in Quality, Patient Safety, Government Regulations, Legal Services, Healthcare, and Regulatory Affairs required.
• Licensed Registered Nurse upon hire preferred.
• Demonstrated leadership skills.
• Knowledge of healthcare and regulatory affairs.
• Analytical, inquisitive, persistent, and detail-oriented.
• Strong work ethic that is fair, moral, objective, and discreet.
• Project management and computer skills.

Benefits

• Comprehensive health benefits
• Flexible spending and health savings accounts
• Retirement savings plan
• Paid time off (PTO)
• Short-term disability
• Education assistance
• Financial education and support, including DailyPay
• Wellness and Wellbeing programs
• Caregiver support via Wellthy
• Childcare referral service via Wellthy