Ent Amb Regulatory Prog Mgr

About the role

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. Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require. 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 Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-