Regulatory Specialist - HUP (Full-Time Days)

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:

• Supports the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with the hospitals within the University of Pennsylvania Health System (UPHS), operating under the licenses of said hospitals and its leaders and staff to ensure full compliance with state licensure regulations, hospital conditions of participation and accreditation standards. Actively participates and leads the organization's efforts to prepare for, take part in and respond to any necessary follow-up of both announced and unannounced regulatory body site visits with a focus on the Clinical Practices of the University of Pennsylvania. Responsibilities also include educating staff to hospital accreditation and licensure standards and regulations. Researches and completes applications, such as the Pennsylvania Department of Health (PA DOH) application and surveys, such as the American Hospital Association (AHA) survey. Actively works with policy owners to support current and develop new Administrative and Clinical hospital polices. Supports team projects and brings groups to consensus on strategies and/or actions necessary to improve clinical quality and/or safety outcomes. Develops, maintains and documents in requisite databases in order to track activities and ensure continuous process improvement and efficiency within the organization and department.
• Demonstrates understanding of concepts, methods, techniques and principles needed to accomplish job responsibilities, such as PA DOH, The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) regulations.

Responsibilities:

• Essential Accountabilities:Ensure internal clients are aware of services offeredSupports the vision of the UPHS Clinical Effectiveness and Quality Improvement DepartmentDevelop relationships within the organization to ensure effective communication and partnership / cooperation in all facets of the licensure and accreditation processCollaborate with leaders and staff to evaluate proposed rules / regulations and assess, develop, or participate in, as appropriate, regulatory advocacy approachesCoordinate with others, as appropriate, to resolve highly complex or unusual business problems impacted by proposed or final regulatory action or inaction affecting major functions or disciplinesOperations: Maintains a solid working knowledge of regulatory body regulations, including but not limited to, TJC, CMS, and PA DOH Maintains a working knowledge of quality outcome related publicly reported data and identifies areas where compliance is problematic Works with individual clinicians and teams to identify methods to improve compliance with clinical quality indicators required by regulators Monitors consistency, validity, and reliability of data. Edits as appropriate Coordinates and participates in regulatory survey readiness activities Coordinates projects in support of clinical quality improvement, e.g., RCA and FMEA processes. Researches and completes surveys, such as the AHA survey, which describes institutional demographics and activities Coordinates quality team projects and brings groups to consensus on methods necessary to improve clinical quality outcomes Facilitates identification of future performance improvement initiatives and organizes appropriate team members Develops, documents in, and maintains databases necessary to track compliance activities and outcomes. Ensures that all initiatives are in compliance with accrediting, regulatory, and institutional standards Maintains the confidentiality of all inter-departmental correspondence as well as the external clients Primary liaison with state agency, including but not limited to PA DOH Collaborates with physicians, administration and staff to achieve desired patient outcomes Assesses educational needs and provides information and instructional materials to HUP departments Educates staff on key policies and procedures and regulatory requirements Conducts Environment of Care rounds and assists in Patient Safety rounds Serves as a liaison with HUP Pharmacy and Infection Control Departments to identify and solve patient care issues with HUP managers and staff

Credentials:

• Registered Nurse - PA

Education or Equivalent Experience:

• Bachelor of Arts or Science (Required)
• Education Specialization: Equivalent Experience: •And Minimum 3-5 years of experience in healthcare management or healthcare education
• Master of Arts or Science
• Education Specialization: Masters of Science in Nursing (MSN) or equivalent Equivalent Experience:

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 and Affirmative Action 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.