Accreditation Program Specialist

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The Health System Wide Ambulatory Accreditation/Regulatory Specialist supports 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 work in conjunction with the Enterprise Ambulatory Accreditation/Regulatory Program manager (Program Manager) on the health system wide ambulatory/outpatient regulatory and accreditation program, providing guidance and recommendations for the outpatient practice conversions to hospital-based physician practices and will assist with continual accreditation readiness, for assigned areas. The specialist collaborates with local hospital regulatory and leadership teams to ensure survey readiness through education and rounding opportunities for outpatient practices that are under the Jefferson Hospital licensure.

Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

middot; Demonstrates an understanding of the Department of Health (DOH), Joint Commission and CMS

regulations as they pertain to enterprise clinics/PBPs under hospital licensure.

middot; Highly skilled in the interpretation of the DOH regulations and accreditation standards, effectively

communicates organizational gaps identified and provides written summaries as required by

Program Manager.

middot; Works collaboratively with Program Manager to convert hospital clinics to hospital-based practices

providing input and assessments when necessary

middot; Monitors publicly reported outcomes or data and communicates trends or concerns with

local/regulatory leaders and Program Manager and ensures system failures are reported promptly

and appropriately.

middot; Leads meetings with hospital-based practice leaders when necessary.

middot; Rounds on a scheduled basis at Provider Based Practices to assess for TJC survey readiness. Assures

timely resolution of observed issues and conflicts from the PBP rounds.

middot; Assists with all aspects of accreditation and regulatory affairs program for assigned areas, including

identifying, developing, and implementing methods to improve the safety and quality of the

services provided to the patients, in order to achieve and maintain compliance with all regulatory

requirements.

middot; Collaborates with hospital regulatory and PBP leaders, problem solves issues presented and

escalates to program manager when necessary.

middot; Perform other duties as assigne

Education:

Bachelor#39;s degree required.

AND

Experience:

Minimum of 2 years of healthcare accreditation and regulatory experience required and provider-based

practice experience highly preferred. Previous experience converting outpatient clinics to hospital based

practices is highly desirable

About Jefferson

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#39;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 educashy;tional 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.