Under the direction of the Accreditation Program Manager and in collaboration with department members and key stakeholders, the Accreditation Program Specialist assists the Director and Manager with the regulatory compliance program for assigned areas. These areas may include any of the Jefferson center city hospitals, surgical centers and/or hospital-based physician practices. The duties include, but are not limited to, assisting with the completion of survey applications, survey preparation activities, on-site surveys, ongoing compliance with all regulations, response to complaints submitted to regulatory bodies, developing corrective action plans and recommended improvements, decreasing duplicative and non-productive efforts, and working to ensure compliance with The Joint Commission (TJC), CARF, the Department of Health of the Commonwealth of Pennsylvania, and other regulatory bodies and requirements that may present themselves from time to time.

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

• Has basic knowledge of Federal and State hospital regulations and accreditation standards. Over time, develops and achieves competency.

• Assists with all aspects of the divisionrsquo;s accreditation and regulatory affairs program for assigned areas, including identifying, developing, and implementing methods to improve the safety and quality of the services provided to the patients, in order to achieve and maintain compliance with all regulatory requirements.

• Collaborates with regulatory team to develop, implement and monitor corrective action plans, when necessary.

• Monitors, reviews, and advises units across the organization to ensure consistent compliance with on-going and new accreditation requirements; supports compliance efforts for programs that have or seek professional accreditation.

• Assists in the planning, organizing and oversight of formal accreditation or regulatory on-site surveys. Takes lead role, as assigned.

• Coordinates reviews by the PA DOH Acute and Ambulatory Care (DAAC) Division

Education:

Associatersquo;s degree required. Bachelorrsquo;s Degree strongly preferred.

AND

Experience:

Must have at least 2 years of experience in hospital operations with some knowledge and experience working with accreditation and regulatory affairs. This may include working in an administrative role.