Job Summary:

Under the general direction of the Director of Regulatory Affairs, executes the hospitalrsquo;s regulatory readiness processes to assure compliance with regulations and standards of regulatory and accreditation agencies. Assesses and determines survey readiness and compliance to all accrediting and licensing agencies by identifying areas of noncompliance and works with leaders to establish effective action plans. Provides ongoing information and education on changes and updates to The Joint Commission, CMS, and Department of Health standards and other agenciesrsquo; requirements. Actively participates in safety and quality initiatives throughout the organization.

Essential Duties:

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson
• Meets all standards of the Patient Satisfaction Initiative Criteria in order to make Jefferson Abington amp; Lansdale Hospitals the hospital of choice for Patients and Employees
• Analyze the regulatory forces (TJC, DOH, CMS, etc.) that impact the care given to patients and lead initiatives to assure and maintain compliance with these organizations.
• Produce critical assessments of current state and assist in the creation of organizational improvement plans by collaborating with other appropriate staff. Perform patient care tracers, assist in running readiness drills and produce outcome reports using a project management framework throughout the organization.
• Collaborate with the Director of Regulatory Affairs in assessing the hospitalrsquo;s compliance with regulatory and accreditation standards from organizations such as The Joint Commission (TJC), Pennsylvania Department of Health (DOH), and the Centers for Medicare and Medicaid Services (CMS)
• Independently, interacts with collaborating departments and administrative leaders responsible for licensure, accreditation and certification programs to achieve compliance with various standards and regulations including TJC, DOH, CMS, DEP, DHS, etc.
• Collaborates with leadership and staff to implement practical applicability of standards.
• Collaborates with department directors to integrate standards with organizational policies and procedures.
• Collaborates with Director of Regulatory Affairs and hospital leaders in performance initiatives to advance regulatory performance.
• Collaborates with department and unit leaders to develop corrective action plans when required. Act as TJC Chapter Leader in collaboration with the department directors and other leaders as appropriate.
• Responsible for working as a designee to the Director of Regulatory Affairs for all external reporting requirements, such as DOH reporting of infrastructure failures, plans of correction, Attestations for new services or equipment, Joint Commission complaints and during on site regulatory surveys
• Independently, performs project management and data analysis activities as directed by the Director of Regulatory Affairs to achieve organizational goals. Serve as a change agent throughout thehospital via teaching and leading process redesign initiatives that impact hospital operations and patient care in order to streamline care in a safe and efficient manner.
• Reviews current regulatory standards for adherence to guidelines, works with available references and resources to maintain knowledge of regulatory standards.
• Performs other duties as assigned.

• Registered Nurse, Bachelorrsquo;s Degree required
• Masterrsquo;s Degree in healthcare field preferred
• Valid PA RN license
• Knowledge of DOH, TJC, CMS, DEP, DHS, etc. regulatory standards
• High level of organizational skills and use of project management tools
• High emotional intelligence
• Ability to communicate effectively with key stakeholders at all levels of the organization
• Change agent/leader
• 3 yearsrsquo; experience healthcare quality or management experience required.
• Strong project management experience; experience in training users (one on one and large groups) with varying levels of skill and clinical knowledge.
• Excellent interpersonal and communication skills, both written and verbal.
• Ability to prioritize and function effectively with teams.
• Proficiency in Microsoft Word, Excel, Power Point, and healthcare related software programs.

Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.

Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.

Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnetreg;-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.

Jeffersonrsquo;s mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

• OUR MISSION: We improve lives.
• OUR VISION: Reimagining health, education and discovery to create unparalleled value
• OUR VALUES: Put People First, Be Bold amp; Think Differently and Do the Right Thing

As an employer, Jeffersonmaintains 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.