General Summary
Provides highly skilled support of assigned Accreditation and Licensure Team (ALT) areas. Provides direction and leadership to the organization by coordinating activities designed to achieve and maintain compliance with accreditation, licensure and other regulatory requirements such as the CMS Conditions of Participation, PA Department of Health, and DNV and other accreditation standards as they apply, in both inpatient and outpatient hospital licensed entities, other licensed entities, and any compliance areas as they pertain to the WellSpan Medical Group/Service Lines (WMG). Independently performs a variety of audits, analysis of the data as well as ensure compliance with regulatory audits, and certifications. Serves as a resource for risk management matters for supported areas. Participates in on-site and virtual survey activities.
Duties and Responsibilities
Essential Functions:
- Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure, certifications, and agreements are being met with a state of continuous survey readiness
- Works closely with the Leadership to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications, and challenges.
- Schedules and coordinates survey related and improvement activities including but not limited to agendas, site visits and educational opportunities.
- Educates others in interpretation of standards and assists as needed in planning improvement/compliance. Facilitates the integration of new accreditation, certification, and regulatory requirements. If supporting the WMG, coordinates regulatory and quality improvement standards such as the following areas: Patient Centered Medical Home (PCMH), Immunization guidelines, Vaccines for Children (VFC) Program, Urgent Care Accreditation, Licenses and Permits surrounding Clinical Laboratory Improvement Amendments (CLIA) and other areas as identified.
- Ensures that mock tracer and audit activities take place as appropriate to ensure survey readiness and compliance with regulatory requirements and develops and monitors action plans that are developed to address opportunities identified through the activities.
- Coordinates regulatory and quality improvement standards. If supporting the WMG, coordinates regulatory and quality improvement standards such as the following areas: Patient Centered Medical Home (PCMH), Immunization guidelines, Vaccines for Children (VFC) Program, Urgent Care Accreditation, Licenses and Permits surrounding Clinical Laboratory Improvement Amendments (CLIA) and other areas as identified.
- Keeps abreast of appropriate regulatory, accreditation, and risk management requirements and best practices.
- Develops collaborative networking relationships with colleagues responsible for regulatory compliance activities.
- Knowledgeable about Lean methodologies, International Organization for Standardization (ISO) standards and tools and uses Performance Improvement tools to implement effective process improvements.
Common Expectations:
- Develops, establishes, and implements goals, objectives, and policies and procedures for department/service line/entity operation, which guide and support the provision of the department/service line/entity's services.
- Continuously assesses and improves the department/service line/entity’s/ performance. Maintains appropriate quality control/assessment programs (if applicable).
- Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
- Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
- Maintains highly confidential information, documentation, and correspondence.
Qualifications
Minimum Education:
- Associates Degree Required
- Bachelors Degree Preferred
Work Experience:
- 2 years In Quality, Patient Safety, Government Regulations, Legal Services, Healthcare and Regulatory Affairs. Required and
- 3 years Experience as an Accreditation and Licensure Specialist or equivalent in the case of an external hire. Required
Licenses:
- Healthcare Accreditation Certified Professional within 180 days Required or
- Certified Healthcare Operations Professional within 180 days Required
- Licensed Registered Nurse Upon Hire Preferred or
- Registered Nurse Multi State License Upon Hire Preferred or
- Licensed Practical Nurse Upon Hire Preferred or
- Licensed Practical Nurse Multi State License Upon Hire Preferred or
- Certified Medical Assistant Upon Hire Preferred or
- Registered Respiratory Therapist - NBRC Upon Hire Preferred or
- Licensed Physical Therapist Assistant Upon Hire Preferred or
- Certified Occupational Therapy Assistant Upon Hire Preferred or
- Registered Health Information Administrator Upon Hire Preferred or
- Medical Technologist - ABOR Upon Hire Preferred or
- Certified Medical Laboratory Scientist - AMT Upon Hire Preferred or
- Certified Medical Laboratory Technician - ASCP Upon Hire Preferred
Knowledge, Skills, and Abilities:
- Demonstrated leadership skills.
- Demonstrated knowledge of health care and regulatory affairs.
- Must have a global view of the Organization's vision and mission.
- Needs to be analytical, inquisitive, persistent, and detail-minded.
- Just Culture is essential in dealing with possible misconduct.
- Must possess a work ethic that is fair, moral, objective, and discreet.
- Project management and computer skills are required.
Benefits Offered:
- Comprehensive health benefits
- Retirement savings plan
- Paid time off (PTO)
- Education assistance
- Financial education and support, including DailyPay
- Expanded Paid Parental Leave
For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)
