Regulatory & Quality Manager

Job Details

Job Description

Under the direction of the Directors, Regulatory and Quality, the Regulatory & Quality Manager is responsible for general regulatory functions that include but are not limited to management of the Policy Accreditation Committee and planning and managing the operations related to the Thomas Jefferson University Hospitals, Inc., Medical Staff Peer Review (under the direction of the Quality Director)

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

* Supports all functions of the accreditation and regulatory affairs program, including the completion of survey applications, leading survey preparation activities as well as on-site survey teams, the assurance of ongoing compliance with all regulations, response to complaints submitted to regulatory bodies, the prioritization of corrective actions and recommended improvements, and working to ensure compliance with The Joint Commission (TJC), CARF, the Department of Health of the Commonwealth of Pennsylvania, and other regulatory bodies.. Tracks progress of improvement plan for issues raised by these regulatory bodies.
* Supports the Policy Accreditation Committee, which includes updating TJUH Inc. policies with the Chair of the Committee and the Regulatory Director.

Manages and supports the Medical Staff peer review process under the direction of the peer review lead, which entails a review of and analysis of medical records, data collection, and data aggregation. Serves as the liaison between various committees to facilitate communication and referral of cases for further clinician review, and report results back to the referring committee.
* Applies clinical knowledge to identify cases meeting criteria for peer review triggers and those requiring further analysis through assessment of information from various data systems.
* Coordinates and communicates with Department and Medical Staff committee membership to assure consistent screening and scoring of select cases for peer review.

Coordinates with the Quality Director to generate reports for Chief Medical Officer/Associate Chief Medical Officers, Department Chair and Division Chiefs, designated Medical Staff and Hospital Committees and Medical Staff leadership.

* Maintains knowledge of The Joint Commission and Centers for Medicare and Medicaid Services requirements pertaining to the medical staff peer review process.
* Assures compliance with ongoing process for archival of peer review related minutes, documents, policies, and files to mitigate legal and regulatory risk. Maintains confidentiality and HIPAA.
* Maintains working knowledge of Thomas Jefferson University Hospitals, Inc. Medical Staff Bylaws, Rules and Regulations and associated policies as related to the peer review process
* Documents all steps of Medical Staff Peer Review Committee management, including minutes and letter generation, tracking action items, action plan follow-up and resolution. Ensures escalation or loop closure of action items.
* Leads and facilitates integration and alignment of key ISFP tactical and operational projects and teams using the Jefferson Performance Excellence Project Management tools.
* Updates key stakeholders of overall progress of peer review process. Communicates with and listens to management staff to understand and resolve the challenges/barriers to ensure the smooth execution/implementation of process improvement activities; identifies problematic issues, escalates, and recommends appropriate solutions.
* Collaborates with the medical staff office, legal, regulatory, and hospital administration to ensure compliance with all applicable standards and requirements around the peer review process.
* Identifies, escalates, and tracks loop closure for disruptive physician/behavioral events, as detailed in policy 120.08.

Competencies (Knowledge, Skills, and Abilities Required):

Data Gathering and Reporting - TAC170
Knowledge of and ability to utilize tools, techniques, and processes for gathering and reporting data in a particular department or division of a company.
Regulatory Affairs
Knowledge of accreditation and licensing standards.
Clinical Policies and Standard - THEM0070
Knowledge of and ability to use industry standards, policies and procedures relevant to function and organization.
Healthcare Knowledge - THNU0080
Knowledge of the operating principles, major issues, governmental regulations, and code of ethics for the healthcare industry, ability to apply this understanding appropriately to healthcare related situations.
Project Management - M0250
Ability to plan, organize, monitor, and control projects, ensuring efficient utilization of technical and administrative resources, to achieve project objectives.
Problem Solving - I0350
Knowledge of approaches, tools, techniques for recognizing, anticipating, and resolving organizational, operational or process problems, ability to apply this knowledge appropriately to diverse situations.
Effective Communications - I0480
Understanding effective communication concepts, tools and techniques, ability to effectively transmit, receive, and accurately interpret ideas, information, and needs through appropriate communication behaviors.

Minimum Education and Experience Requirements:

Bachelor of Science in Nursing or ancillary clinical healthcare field required. MSN or master's degree in business or healthcare administration preferred.
AND
Experience:

2-3 years hospital regulatory experience preferred.
Experience running reports and aggregating data preferred.
Manager - Please indicate minimum level of education and experience for this job. Please indicate whether it is required or preferred.

Minimum Certifications, Registration or License Requirements:
Current licensure as a Registered Nurse or other Professional Clinical Position in the Commonwealth of PA.

Work Shift

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Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.