Program Manager, Regulatory and Accreditation

Nevada System of Higher Education•Glenview, IL

2d•$47 - $73•Hybrid

About The Position

Reporting to the Assistant Vice President Accreditation, Regulatory and Compliance, this role coordinates and serves as the primary contact for system-wide complex accreditation, certification, and regulatory activities. This includes the review of abuse allegations, survey preparation, and readiness assessments for facilities within Endeavor Health. The Program Manager will 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), as well as other State and Federal agencies.

Requirements

Bachelors Degree Required
5 Years experience in a clinical setting.
3 Years experience in quality, risk management, or regulatory/accreditation role.
Familiarity with TJC, CoP, IDPH, EPIC and hospital clinical and operational workflows, and admin functions.
Commitment to staying current with evolving regulations, standards, and best practices in healthcare.
Excellent written and presentation skills.
Managing accreditation/change projects, including timeliness, resource allocation, and team coordination.
Data analysis and proficiency in MS Excel.
Effective writing skills for policies, procedures, and compliance reports.
Ability to collect, analyze, and report data to demonstrate compliance.
Ability to navigate complex regulatory and legal issues related to healthcare delivery.
Ability to effectively communicate regulatory requirements and changes to all levels of staff and leadership.
BLS – Basic Life Support (CPR and AED) - American Heart Association (AHA) Required
Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Preferred
Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety (CBPPS) Preferred
CHRM, CPPS, or CQP preferred

Nice To Haves

Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety (CBPPS)
CHRM, CPPS, or CQP

Responsibilities

Lead preparation for regulatory activities at assigned entities, departments, business lines, 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 lines, and/or institutes senior and executive leaders, 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 with system accreditation and regulatory activities, including survey preparation and readiness assessments.
Assist with the interpretation of standards and regulations, and serve as a secondary point of contact for accreditation bodies.
Assist AVP in providing education for the organization leaders regarding regulatory and accreditation issues.
Identify learning needs and opportunities, and research training content and methods in collaboration with key impacted areas.
Monitor regulatory websites for new information and new or revised standards, collaboratively evaluate compliance towards those changes, and be instrumental in the development, assessment, and achievement of organization readiness.
Lead readiness efforts at assigned entities, departments, and/or institutes.
Lead standardization of regulatory workflows associated with assigned system policy and departments (e.g., clinical contract reviews, supply chain, HIM, etc.).
Co-lead abuse and key sentinel investigations with local or system leaders, ensuring 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 audits and reviews to ensure compliance with provider-based rules, co-location rules, ADA, and other regulatory requirements.
Other duties as assigned.