Ambulatory Regulatory & Accreditation Program Manager - Jefferson Health Systems

About the role

The Jefferson Health Systems Ambulatory Accreditation/Regulatory Program Manager oversees the ambulatory clinic/physician based practices (PBP) within the Jefferson Health system to ensure compliance with state licensure regulations, CMS conditions of participation, and Joint Commission standards. They also manage the enterprise ambulatory/outpatient regulatory and accreditation program, providing oversight, guidance, and recommendations for the transition of outpatient practices to hospital-based physician practices and maintaining continual accreditation readiness.

Responsibilities

• Serves as the subject matter expert for DOH, Joint Commission, and CMS regulations related to enterprise clinics/PBPs under hospital licensure.
• Communicates organizational gaps identified by regulations to local and enterprise leaders and implements action plans to meet standards or close gaps.
• Manages the communication of proposed and new regulations/standards/updates to clinics/PBPs and local leadership through structured meetings/emails.
• Delivers recommendations 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.
• Develops and manages the PBP rounding schedule, distributes findings, and reviews actions plans with clinics/PBPs leadership teams.
• Affirms timely resolution of observed issues and conflicts from PBP rounds.
• Collaborates with hospital regulatory and PBP leaders to resolve complex or unusual business problems related to proposed or final regulatory actions.

Requirements

• Bachelor’s Degree in Healthcare Administration, Public Health, or a related field.
• 4 years of healthcare accreditation and regulatory experience.
• Expert knowledge of PADOH, NJDOH, CMS, FGI, and TJC standards/guidelines.
• Capable of working independently and handling competing priorities.

Preferred Qualifications

• Master’s Degree in Healthcare Administration, Public Health, or a related field.
• 4 years of provided based practice experience.

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.