Accreditation and Regulatory Standards Specialist- Full Time

Penn Medicine; Lancaster (Lancaster County); On-site; USD 90,000 - 110,000; Full time

Job summary

Penn Medicine is seeking a Regulatory Specialist to collaborate with leadership to ensure regulatory readiness across state, federal, and joint commission requirements. You will lead education efforts, mentor operations teams, and drive data-driven compliance across acute and ambulatory settings.

You will coordinate licensure, accreditation surveys, and plan of corrections, supporting system-wide regulatory goals and AMP system administration.

Qualifications

• Bachelor's degree in a healthcare-related field.
• CPHQ CPPS or another related certification within 30 months of hire.
• Five years of experience in a healthcare environment.
• Ability to manage multiple projects and priorities.
• Strong written, verbal, and presentation skills.
• Proficiency with Microsoft Office and data analysis tools.

Responsibilities

• Maintain current regulations across state, federal, and joint commission requirements.
• Provide leadership, education, and mentoring to stakeholders.
• Collect, analyze, and report regulatory data to support leaders.
• Coordinate licensure, certification, and accreditation surveys.
• Develop plans of correction and respond to citations.
• Support regulatory goals and tracer/AMP system administration.

Skills

Regulatory knowledge

Leadership

Communication

Microsoft Office

Data analysis

Education

Bachelor's degree in healthcare related field

CPHQ/CPPS certification

Tools

Statistical software

AMP system

Job description

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

• Position Summary: The regulatory specialist works collaboratively with organizational and physician leadership to impart regulatory knowledge and maintain continuous regulatory readiness. Provides leadership, education, and mentoring to operational stakeholders with planning, developing, implementing and evaluation of regulatory activity.
• Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties:
• Maintains a strong working knowledge of current regulations for all state, federal and joint commission requirements both in the acute care hospital system and ambulatory settings. Effectively communicates any changes in interpretation to appropriate organizational leaders and provides coaching to develop action plans as needed to assess, monitor and comply with current changes.
• Researches, conducts analysis, and validates accuracy of data and information submission to state, federal, accrediting agencies, and national database- hospital ranking association
• Assists in collecting data, creating reports, interpreting and analyzing data in order to support leaders in identifying both gaps in performance and regulatory compliance.
• Collaborates with the medical, clinical and operational leaders at all levels executive, director and front line to foster a culture of engagement, collaboration and shared accountability to ensure a state of perpetual readiness
• Anticipates and coordinates licensure, certification and accreditation onsite survey logistics and coordinates activities to support both scheduled and unannounced inspections
• Leads new service equipment attestation processes
• Provide support to the creation of plan of correction responses to state and federal citations
• Participates in the development and implementation of regulatory goals consistent with those of the health system
• Acts as a mentor or coach on tracer rounding and AMP system. Functions as system administrator of the AMP system.
• The following duties are considered secondary to the primary duties listed above:
• Perform budget manager responsibilities for the department, including investigating variances.
• Manages department equipment, supplies, physical office environment and department specific systems.
• Participates and represents ARS department as a specialist for hospital or system-wide committees as directed
• Provides back-up to administrative function staff
• Other duties as assigned.

Responsibilities

• Minimum Required Qualifications:
• Bachelor’s Degree in healthcare related field
• CPHQ CPPS or other related certification within 30 months of hire
• Five 5 years’ experience in healthcare environment
• Ability to simultaneously manage multiple projects priorities successfully
• Effective written, verbal, presentation and communication skills
• Ability to work collaboratively with leadership and staff to achieve regulatory initiatives
• Proficiency in Microsoft office and other electronic software applications
• Five 5 years’ experience with maintaining regulatory, safety and quality standard within an acute healthcare setting
• Experience with statistical software and or other data analysis and visual display of data
• Attention Concentration: The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others.
• .
• The position requires the ability to attend to more than one aspect of a situation simultaneously. It is highly likely that multiple task demands are going to be required of the individual at the same time.
• New Learning and Memory: The following level of ability is essential for the jobholder to learn and retain material.
• The position requires that an individual be able to learn new tasks quickly and effectively. change frequently. The ability to understand and carry out detailed, involved instructions is mandatory.
• Problem Solving, Reasoning and Creative Thinking: The following level of ability that is essential for the jobholder to think in order to solve a problem by combining two or more elements from past experience or imaginative thought.
• The position requires much autonomy of thought and problem solving. The individual must be able to apply principles of logical or scientific thinking to define problems. The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem. The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis. The individual must be able to collect data, establish facts, and draw valid conclusions. The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition. They must be able to deal with a variety of concrete and abstract variables.
• The following are essential requirements of the position in relation to job-worker situations. These items describe how a worker must adapt, adjust, conform or act.
• Leadership, control and planning: Ability to accept responsibility for leadership, direction, control, planning, negotiating, organizing, directing, supervising, formulating practices, or making final decisions.
• Repetitive work: Ability to continuously perform the same type of work for extended periods of time, according to set procedures, sequence or pace.
• Performing under stressful conditions: Ability to perform under stress when confronted with emergency, critical, unusual, or dangerous situations, or in situations in which working speed and sustained attention are critical aspects of the job. Is subject to danger or risk, or to tension as a regular, consistent part of the job.
• Variety and change: Ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure involving significant differences in technologies, techniques, procedures, environmental factors, physical demands, or work situations.
• Communication: Ability to exchange information with others clearly and concisely; to present ideas, facts and technical information.
• Interpersonal relations: Ability to maintain relationships that facilitate task accomplishment; to cooperate and resolve conflicts; to recognize needs and be sensitive of others.

Education or Equivalent Experience

• Bachelor of Arts or Science (Required)

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.