Program Manager, Regulatory and Accreditation

nshs

Glenview (IL)

On-site

USD 63,000 - 99,000

Full time

5 days ago

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Benefits offered by this job

Premium pay for eligible employees

Career Pathways to Promote Growth

Medical, Dental, Vision options

Tuition Reimbursement

Free Parking at designated locations

Wellness Program Savings Plan

Health Savings Account Options

Retirement Options with Company Match

Paid Time Off

Community Involvement Opportunities

Job summary

Endeavor Health in Glenview, IL seeks a Program Manager, Regulatory/Accreditation to coordinate system-wide accreditation and regulatory activities. You will lead readiness, develop compliance strategies with senior leadership, and oversee responses to Joint Commission and IDPH surveys while ensuring continuous regulatory readiness across facilities.

Requirements include a bachelor's degree, 5+ years in a clinical setting, and 3+ years in quality, risk management, or regulatory roles.

Qualifications

Bachelor's degree required.
5+ years of clinical setting experience.
3+ years in quality, risk management, or regulatory/accreditation role.
Familiarity with TJC, CoP, IDPH, EPIC and hospital workflows.

Responsibilities

Lead preparation for regulatory activities at entities, departments, or institutes.
Develop compliance strategies with senior leadership.
Oversee regulatory reporting with quality and other departments.
Lead responses to Joint Commission and IDPH post-survey actions.
Assist with survey readiness and accreditation activities.
Interpret standards and regulations for organization staff.

Skills

Written communication

Presentation skills

Project management

Data analysis

MS Excel

Policy writing

Education

Bachelor's degree

Tools

EPIC

Job description

Hourly Pay Range: $46.79 - $72.52 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position Highlights

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

A Brief Overview

Reporting to the Assistant Vice President Accreditation, Regulatory and Compliance, coordinates and serves as primary contact for system wide complex accreditation, certification and regulatory activities, including review of abuse allegations, survey preparation and readiness assessments for facilities within Endeavor Health.

Lead and support entity/business line compliance with The Joint Commission (TJC), the Accreditation Commission for Health Care (ACHC), Accreditation Association for Ambulatory Health Care (AAAHC), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid Services (CMS) and other State and Federal agencies.

What you will do

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.

What you will need

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

Benefits (for full and parti-time positions)