Accreditation Program Manager

Jefferson Health Plans•East Norriton Township, PA

3d•Onsite

About The Position

Interacts with internal leaders and external surveyors to sustain hospital licensure, accreditation, and certifications necessary to support organizational mission, vision, strategies, network goals, and strategic business objectives. Improves networkwide and department leader understanding of regulatory requirements serving as an innovative, strategic subject matter expert in the continuous readiness infrastructure. Cocreates, executes, evaluates, and adjusts short- and long-term team and departmental goals to proactively identify and rectify cited vulnerabilities. Cultivates a strengths-based culture of continuous improvement through the Plan, Do, Study, Act, process.

Requirements

Bachelor’s Degree in Clinical area or health-care related field.
5 years experience in acute care hospital nursing, patient-care, Home Care, Hospice or other hospital operations experience.
Extensive team facilitation and project management skills.
Proficiency in Microsoft Suite: (Word, Excel, PowerPoint, Outlook).
Ability to solve problems and build consensus.
Highly organized with the ability to work well with people.
Ability to work with highly sensitive and confidential information.
Demonstrated knowledge of the Joint Commission accreditation and program certification standards and the Pennsylvania Department of Health (DOH) regulations, with the ability to interpret, implement and monitor compliance requirements.

Nice To Haves

Master’s Degree in health-care related field.
2 years of Quality, regulatory or accreditation experience in a healthcare organization.
RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Responsibilities

Maintains expertise for all state Department of Health (DOH) Hospital Facilities regulations, The Joint Commission (TJC) accreditation and certification standards, and Centers for Medicare and Medicaid (CMS) Conditions of Participation assisting leaders with applicability across all healthcare programs. Synthesizes proposed and new standards for impact on all appropriate system wide programs.
Conducts complex gap analyses across the network to proactively identify vulnerabilities of deficiency that could result in potential patient harm or interruption of accreditation or licensure through tracers, environmental consultation, and physician practice conversion assessments.
Designs, plans, delivers, evaluates, and continually supports specialty certification and licensure needs for startup and ongoing programs such as Stroke, LVAD, Transplant, Ambulatory Surgery Centers, Behavioral Health, and Skilled Nursing. Serves as a subject matter expert and integral team member.
Manages external regulatory and accreditation surveyors during formal onsite inspections for ongoing hospital licensure, occupancy, accreditation, and certifications of all campuses and off-site locations under the LVH license. Adeptly mitigates risk, navigates hospital policies, interacts with internal subject matter experts, and leads survey activities to ensure evidence of compliance is provided in a timely manner. Provides onsite survey support to other LVHN regions.
Completes complex regulatory assessments of strategic initiatives for multifarious physician practice Hospital Outpatient Departments (HOPD) conversions, micro-hospitals, and renovation & expansion projects to provide clients and business partners status, results, and feedback for state licensure readiness of network strategic initiatives.
Assists in preparing documents required for hospital licensure and accreditation for all hospital campuses and off site locations.
Develops and delivers comprehensive educational and training programs necessary for ongoing and emerging licensure and accreditation based on a complete needs assessment.
Supports all Quality, Patient Safety, and Infection Control initiatives.
Collaborates with Project Coordinator on special project design and implementation.
Assists Risk Management with onsite Department of Health complaint investigations as needed.