Accreditation Program Manager

Number of Positions In Requisition

1

Job Details

Accreditation Program Manager

Job Description

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. 

ESSENTIAL FUNCTION

·       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.

ADDITIONAL RESPONSIBILITIES

·       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.

QUALIFICATIONS

 

Education - Required

·       Bachelor’s Degree in Clinical area or health-care related field.

Education - Preferred

·       Master’s Degree in health-care related field.

Experience - Required

·       5 years experience in acute care hospital nursing, patient-care, Home Care, Hospice or other hospital operations experience.

Experience - Preferred

·       2 years of Quality, regulatory or accreditation experience in a healthcare organization.

Knowledge, Skills and Abilities - Required

·       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 knowle4dge 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.

Licenses and Certifications - Preferred

·       RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Albert Einstein Medical Center

Primary Location Address

559 W. Germantown Pike, East Norriton, 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-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

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. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem  colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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