200929 Program Manager Regulatory Compliance

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Business Administration, Healthcare Administration, Nursing, or other related field.

EXPERIENCE:

1. 5 year's professional experience in a healthcare setting.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Master's Degree in health related field (e.g. MHA, MBA, MPA, MPH)

2. Relevant advanced certification (e.g. PMP, CPHQ, Lean Six Sigma)

CORE DUTIES AND RESPONSIBILITIES:The statements described here are intended to describe the general nature of work being performed by people assigned to this position.They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.Other duties may be assigned.

1. Develop, manage, and maintain programs designed to ensure compliance with accreditation and regulatory standards, including but not limited to: The Joint Commission (TJC), Office of Health Facility Licensure and Certification (OHFLAC), and Center for Medicare and Medicaid Services (CMS).

2. Manage aspects of investigations, inspections and surveys conducted by regulatory and accrediting agencies; prepare for and facilitate regulatory visits and construction occupancies, oversight of the regulatory surveyors; respond to the deficiencies by ensuring appropriate corrective measures have been taken which eliminate the deficiency.

3. Conduct observation audit and chart review to support prioritized opportunities for improvement of projects related to annual operating plan and/or regulatory related topics using PDSA process. Contributes to the assessment of baseline performance and ensures improvement/corrective action plan durability. Manages data collection and recommends improvement to the process and improves workflow.

4. Provide expert regulatory advice and support to internal teams, helping them navigate complex regulatory issues.

5. Maintain a deep understanding of regulatory processes and guidelines at both the state and federal levels specific to healthcare regulations.

6. Analyze and interpret complex regulatory documents, legislation and policy changes.

7. Build and maintain effective relationships with government officials, regulatory agencies, and internal teams.

8. Manage multiple projects simultaneously, prioritizing tasks, and meeting deadlines in a fast-paced environment.

9. Ensure TJC and other regulatory compliance by advising departments services and committees of relevant specific accreditation and regulatory interpretations and any changes to previous regulations. Interprets standards for evidenced-based care as required. Provides instruction on TJC regulations and information on models for clinical improvement efforts. Contacts those responsible for reporting data to determine status and collaborates as needed to achieve compliance with program specifications.

8. Identify problems, analyze potential pathways, and generate effective solutions.

9. Assist in the development of appropriate policies, processes, and activities to support continuous readiness for Joint Commission and Centers for Medicare and Medicaid Services.

10. Prepare the institutional response to Joint Commission, OHFLAC, and CMS findings.

11. Reports thecurrent statusof accreditation or other regulatory activities to Senior Administration.

12. Prepare institutional Annual Periodic Performance Evaluation.

13. Develop assignments for chapter leaders.

14. Manage Environment of Care Reporting and Loop Closure.

15. Ensure that the accreditation readiness program is in place by coordinating 'mock surveys' and collecting required supporting documentation. Participate in the development of educational resources for the general staff regarding standard/regulatory updates.

16. Prepare individual programs for Joint Commission Certifications.

17. Maintains liaison relationship with peers at WVU Medicine system hospitals by coordinating periodic system regulatory meetings.

19. Establish and maintain strong relationships with key stakeholders in regulatory agencies to facilitate effective communication and advocacy.

20. Provide system outreach as appropriate.

22. Lead and participate in organizational committees and meetings.

PHYSICAL REQUIREMENTS:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping, and ability to climb ladders are necessary body movements utilized in performing duties through the work shift.

WORKING ENVIRONMENT:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office and hospital setting.

2. Occasional travel required.

SKILLS & ABILILTIES:

1. Must be proficient in MS Word, Excel, Access and other software to collect, analyze, and present data.

2. Demonstrates assertiveness.

3. Utilizes community and system resources.

4. Must be flexible with workload and schedule.

5. Demonstrates effective interpersonal communication.

6. Demonstrates diplomacy.

7. Demonstrates excellent written and verbal skills.

8. Demonstrates negotiation skills.

9. Ability to analyze and perform analysis and research.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

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WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.