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Job Details
The Jefferson Health Systems Ambulatory Accreditation/Regulatory Program Manager manages 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 manage the enterprise ambulatory/outpatient regulatory and accreditation program, providing oversight, guidance and recommendations for the outpatient practice conversion to hospital based physician practices and for continual accreditation readiness. The Senior Specialist collaborates with local hospital regulatory and leadership teams to manage survey readiness through education and rounding opportunities for outpatient practices that are under the Jefferson Hospital licensure.
**Travel 2-3 days/week to physician practices is required. Primary regions include: Philadelphia, Bucks and Montgomery County, PA, South Jersey, and to the Lehigh Valley region. Flexible hybrid work available on non-office days.**
Job Description
Job Duties

• Serves as the subject master expert for the Department of Health (DOH), Joint Commission and CMS regulations as they pertain to enterprise clinics/PBPs under hospital licensure.
• The Senior Specialist being highly skilled in the interpretation of the DOH regulations and accreditation standards, effectively communicates to local and enterprise leaders the organizational gaps identified and implements action plans to meet standards and/or close gaps. Oversees publicly reported outcomes or data and communicates trends or concerns with local/enterprise leaders. Ensures system failures are reported promptly and appropriately.
• Manages the communication of proposed and new regulations/standards/updates to clinics/PBPs and local leadership through structured meetings/emails and provides valuable input on methods to meet compliance.
• Delivers recommendations (written or verbal) on areas of non-compliance with FGI guidance and regulations during ambulatory practice site conversion assessments and discussions.
• Manages the PA DOH DAAC (or NJ equivalent) occupancy process for new equipment, services, and/or construction projects for the ambulatory/provider based practices. Established subject matter expert for state, federal or regulatory surveys for the PBP/ ambulatory clinics.
• Develops and manages the PBP rounding schedule, distributes findings and reviews the actions plans with the clinics/PBPs leadership teams. Assures timely resolution of observed issues and conflicts from the PBP rounds.
• Collaborates with hospital regulatory and PBP leaders, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplines.

Minimum Qualifications

• Bachelor's Degree
• 4 years of healthcare accreditation and regulatory experience and
• Less than 1 year of previous experience converting outpatient clinics to hospital based practices
• Working expert knowledge of PADOH, NJDOH, CMS, FGI and TJC standards/guidelines.
• Capable of working independently
• Excels in solving problems before they become critical
• Work effectively with others
• Effectively handles competing priorities

Preferred Qualifications

• Master's Degree
• 4 years Provided based practice experience

Additional Qualifications
Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.
Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.
Work Shift
Workday Day (United States of America)
Worker Sub Type
Regular
Employee Entity
Thomas Jefferson University
Primary Location Address
1101 Market, Philadelphia, 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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