Program Manager, Regulatory and Accreditation

Gbh Ambulatory Care Center Glenviewmid

OperationsProject Manager

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Quick Summary

Key Responsibilities

Lead preparation for regulatory activities at assigned entities, departments, business line and/or institutes.

Requirements Summary

Bachelors Degree Required 5+ Years 5 Years experience in a clinical setting. 3 Years 3 Years experience in quality, risk management, or regulatory/accreditation role.

Technical Tools

OperationsProject Manager

$47.72 - $73.97 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position: Program Manager, Regulatory/Accreditation
Location: Glenview, IL
Full Time: 40 hours/week
Hours: Monday-Friday, 8:00a-4:30p
Required Travel: To other Endeavor locations

Responsibilities

~3 min read

→Lead preparation for regulatory activities at assigned entities, departments, business line and/or institutes. Work collaboratively with content area experts in the organization to ensure a continuous state of readiness throughout the organization.
→Develop, in collaboration with assigned entities, departments, business line and/or institutes senior and executive leader on compliance strategies and tactics.
→Provide oversight to required entity regulatory reporting in conjunction with quality and other departments.
→Lead assigned entities’ development and monitoring of responses to the Joint Commission and IDPH related to Evidence of Standards Completion (ESC) or other post survey activity.
→Assist system accreditation and regulatory activities, including survey preparation and readiness assessments.
→Assist with interpretation of standards and regulations, and serves as secondary point of contact for accreditation bodies.
→Assist AVP in providing education for the organization leaders regarding regulatory and accreditation issues. Identifies learning needs and opportunities and researches training content and methods in collaboration with key areas impacted.
→Responsible for monitoring regulatory websites for new information and new or revised standards, collaboratively evaluating compliance towards those changes and is instrumental in the development, assessment and achievement of organization readiness.
→Lead readiness efforts at assigned entities, departments and/or institutes.
→Lead standardization or regulatory workflows associated with assigned system policy and departments (eg clinical contract reviews, supply chain, HIM, etc.).
→Co-lead abuse and key sentinel investigations with local or system leaders, ensure standardization of investigation. Documentation and follow-up. Analyze trends and recommend opportunities for improvement.
→Manage oversight of Tracer & Epic audit reports to support monitoring and reporting of regulatory compliance risk.
→Support Policy Stat workflows at assigned entities, departments, and/or institutes.
→Support regulatory audit and reviews to ensure compliance with provider based rules, co-location rules, ADA and other regulatory requirements.
→Other duties as assigned.
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→Bachelors Degree Required
→5+ Years 5 Years experience in a clinical setting.
→3 Years 3 Years experience in quality, risk management, or regulatory/accreditation role.
→Knowledge: Familiarity with TJC, CoP, IDPH, EPIC and hospital clinical and operational workflows, and admin functions. Commitment to staying current with evolving regulations, standard and best practices in healthcare.
→Skills: Excellent written and presentation skills. Managing accreditation/change projects, including timeliness, resource allocation and team coordination. Data analysis and proficiency in MS Excel. Effective writing skills for policies, procedures and compliance reports.
→Abilities: Ability to collect, analyze and report data to demonstrate compliance. Ability to navigate complex regulatory and legal issues related to healthcare delivery. Ability to effectively communicate regulatory requirement and changes to all level of staff and leadership.
→BLS – Basic Life Support (CPR and AED) - American Heart Association (AHA) Required And
→Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Preferred Or
→Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety (CBPPS) CHRM, CPPS, or CQP preferred Preferred