Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
Summary:
Supports the leaders and staff of the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which fall under HUP's Pennsylvania Department of Health (PA DOH) hospital license to ensure compliance with state licensure regulations, Centers for Medicare and Medicaid Services' (CMS) hospital conditions of participation and Joint Commission (JC) accreditation standards. The Regulatory Specialist actively participates and leads the organization's efforts to prepare for, take part in, and respond to any necessary follow-up of both announced and unannounced regulatory body site visits and inquiries. Responsibilities also include informing staff regarding hospital accreditation standards and licensure regulations. Completes certain regulatory related applications, such as the PA DOH hospital questionnaire, JC applications, and the hospital license application. Actively works with policy owners to provide updated regulatory standards and regulations to ensure Departmental, Administrative and Medical Board hospital policies reference and reflect the most current information. Provides regulatory consultation for internal customer projects to ensure that they are consistent with regulatory agency regulations. Develops, maintains and documents in requisite internal databases in order to track activities, meet document retention requirements, and ensure continuous process improvement and efficiency within the department. Demonstrates understanding of concepts, methods, techniques, and principles needed to accomplish job responsibilities, such as PA DOH, JC, and CMS regulations.
Responsibilities:
Essential Accountabilities: • Ensure internal clients are aware of services offered • Supports the vision of the UPHS Clinical Effectiveness and Quality Improvement Department • Develop relationships within the organization to ensure effective communication and partnership / cooperation in all facets of the licensure and accreditation process • Collaborate with leaders and staff to evaluate proposed rules / regulations and assess, develop, or participate in, as appropriate, regulatory advocacy approaches • Coordinate with others, as appropriate, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplines
Operations: • Coordinates and participates in regulatory survey readiness activities • Ensures that initiatives are in compliance with accrediting, regulatory, and institutional standards • Maintains the confidentiality of all inter-departmental correspondence as well as the external clients • Primary liaison with state agency, including but not limited to PA DOH • Serves as a liaison with hospital departments, including Pharmacy, Infection Control, Radiology, Perioperative Services, Respiratory, etc, to offer consultation and work collaboratively to develop workable solutions to regulatory challenges • Standards Interpretation – Interpretation of PA DOH, CMS (hospital), and TJC regulations/standards. This includes subject matter expertise, partnering with TJC/CMS Chapter Leads, departments, units, and practices to apply regulations to existing operation while staying within institutional policy(ies) (workable solutions).
Survey Readiness Materials & Communications – Develop survey readiness materials for accreditation, certification and other types of surveys which include templates & content for effective & consistent communication of accreditation, licensure, & certification information. Includes surveys, standards, & continuous readiness.
Direct & Indirect Survey Oversight – Directly facilitates all aspects of the triennial TJC accreditation survey (which includes CMS certification & PA DOH licensure surveys). Works with internal customers to provide direction and to shepherd them through the PA DOH Division of Acute & Ambulatory Care (DAAC) occupancy surveys. Works closely with the internal leads of HUP’s 3 TJC Disease Specific surveys (Heart Failure, VAD, and Stroke) to advise on survey logistics & facilitation of surveys. Interfaces with surveyors with onsite complaint investigations & survey activity, including TJC extension & initial surveys and For-Cause surveys; PA DOH DAAC for occupancy surveys and equipment attestations; and CMS complaint inquiries, surveys related to hospital CoPs and PA DOH regulations, validation surveys, full surveys, and onsite regulatory survey activity.
Compliance Activities – Knowledge and continuous assessment of organizational compliance with hospital regulations, including but not limited to: the PA DOH hospital regulations; CMS hospital CoPs, and JC standards. This is accomplished through: completion of monitoring changes in regulations and assessments of compliance; targeted tracer activity; conducting regulatory consultations for internal customers, and facilitating preparation for surveys, including PA DOH surveys.
Risk Mitigation: Identify areas of regulatory risk and potential liability to the organization. Work with operational leaders to implement corrective actions. Investigates noncompliance issues and develops response strategies. • Advisor to Executive / Senior leadership: Track and communicate regulatory trends and implications for hospital operations.
Education or Equivalent Experience:
- Bachelor of Arts or Science (Required) with a Minimum 3-5 years of experience in healthcare management or healthcare education
- Master of Arts or Science (Preferred)Education Specialization:
Masters of Science in Nursing (MSN) or equivalent experience:
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
