Reference #: 9304026 About Jefferson Nationally ranked,Jefferson, which is principally located in the greaterPhiladelphiaregion and southernNew Jersey, is reimagining health care and higher education to create unparalleled value.Jeffersonis more than 42,000 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 SidneyKimmel 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 healthcare systems in the country and the largest provider in thePhiladelphiaarea, serves patients through millions of encounters each year at 17 hospitals and more than 160 outpatient and urgent care locations throughout the region. Jefferson Health Plansis a not-for-profit managed health care organization providing a broad range of health coverage options inPennsylvaniaandNew Jerseyfor more than 35 years. Covid Vaccination is a requirement for employment at Jefferson for employees working at Jeffersonrsquo;s clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson. Under the direction of the Director of Quality and Regulatory Affairs and in collaboration with department members and key stakeholders, the Accreditation Program Manager coordinates the regulatory compliance program for assigned areas. These areas may include any of the Jefferson center city hospitals, surgical centers and/or hospital-based physician practices. The duties include, but are not limited to, the completion of survey applications, leading survey preparation activities as well as on-site survey teams, the assurance of ongoing compliance with all regulations, response to complaints submitted to regulatory bodies, the prioritization of corrective actions and recommended improvements, decreasing duplicative and non-productive efforts, and working to ensure compliance with The Joint Commission (TJC), CARF, the Department of Health of the Commonwealth of Pennsylvania, and other regulatory bodies and requirements that may present themselves from time to time.

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

Knowledgeable in Federal and State hospital regulations and provides expert analysis of regulations and interpretive guidance in order to articulate the intent and value of the regulations.

Coordinates and improves all aspects of the divisionrsquo;s accreditation and regulatory affairs program for assigned areas, including continuously 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.

Collaborates with administrators and leaders to develop, implement and monitor corrective action plans, when necessary.

Guides and collaborates with administrators and departmental staff representatives at all levels to achieve defined goals and objectives related to accreditation compliance activities.

Monitors, reviews, and advises units across the organization to ensure consistent compliance with the on-going and new accreditation requirements; advises and supports compliance efforts for programs that have, or seek professional accreditation.

Plans, organizes, and oversees formal accreditation or regulatory on-site surveys.

May serve as the liaison between the organization and various accrediting/ regulatory bodies.

Minimum Education and Experience Requirements: Education:

Associatersquo;s degree required. Bachelorrsquo;s Degree strongly preferred.

AND

Experience:

Three plus years of experience working with healthcare State and Federal hospital regulations.

As an employer, the Jefferson Enterprise maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.