Ent Amb Regulatory Prog Mgr

Enterprise Ambulatory Accreditation/Regulatory Senior Specialist

Summary The Enterprise Ambulatory Accreditation/Regulatory Senior Specialist manages the ambulatory clinic/physician based practices (PBP) (under the hospital licensure) throughout the Jefferson Health system to ensure compliance with state licensure regulations, CMS conditions of participations and Joint Commission standards. They will manage the enterprise ambulatory/outpatient regulatory and accreditation program, providing oversight, guidance and recommendations for the outpatient practice conversion to hospital based physician practices and for continual accreditation readiness. The Senior Specialist collaborates with local hospital regulatory and leadership teams to manage survey readiness through education and rounding opportunities for outpatient practices that are under the Jefferson Hospital licensure.

Job Duties

• Serves as the subject master expert for the Department of Health (DOH), Joint Commission and CMS regulations as they pertain to enterprise clinics/PBPs under hospital licensure.
• The Senior Specialist being highly skilled in the interpretation of the DOH regulations and accreditation standards, effectively communicates to local and enterprise leaders the organizational gaps identified and implements action plans to meet standards and/or close gaps. Oversees publicly reported outcomes or data and communicates trends or concerns with local/enterprise leaders. Ensures system failures are reported promptly and appropriately.
• Manages the communication of proposed and new regulations/standards/updates to clinics/PBPs and local leadership through structured meetings/emails and provides valuable input on methods to meet compliance.
• Delivers recommendations (written or verbal) on areas of non-compliance with FGI guidance and regulations during ambulatory practice site conversion assessments and discussions.
• Manages the PA DOH DAAC (or NJ equivalent) occupancy process for new equipment, services, and/or construction projects for the ambulatory/provider based practices. Established subject matter expert for state, federal or regulatory surveys for the PBP/ ambulatory clinics.
• Develops and manages the PBP rounding schedule, distributes findings and reviews the actions plans with the clinics/PBPs leadership teams. Assures timely resolution of observed issues and conflicts from the PBP rounds.
• Collaborates with hospital regulatory and PBP leaders, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplines.

Minimum Qualifications

• Bachelor's Degree
• 4 years of healthcare accreditation and regulatory experience and
• Less than 1 year of previous experience converting outpatient clinics to hospital based practices
• Working expert knowledge of PADOH, NJDOH, CMS, FGI and TJC standards/guidelines.
• Capable of working independently
• Excels in solving problems before they become critical
• Work effectively with others
• Effectively handles competing priorities

Preferred Qualifications

• Master's Degree
• 4 years Provided based practice experience

Additional Qualifications Physical Demands Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.