Description

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 within HUP, and its leaders and staff to ensure full compliance with state licensure regulations, hospital conditions of participation and accreditation standards—specifically as pertains to HUP Administrative policies. Oversees, monitors and directs the HUP Administrative policy cycle from creation to implementation, including future revisions, updates and maintenance.

Responsibilities:

• 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

• Controls content of all policies and assists as a gatekeeper for the system.

• Acts as a resource to associates in quality audits, focused audits, and other assigned duties and areas of responsibilities.

• Ability to use personal judgment and initiative to develop effective and constructive solutions to barriers to policy development/revision activity and process

• Demonstrates leadership skills in facilitating with teams to achieve the expected results while engendering cooperation, confidence, and respect from leaders and staff at all levels of the organization

• Able to maintain a record-keeping system for policies, those in development, current, and archived, that is accessible to the HUP Regulatory Team

• Coordinates and participates in regulatory survey readiness activities

• Coordinates projects in support of quality improvement as a policy expert

• 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

Education or Equivalent Experience:

• Bachelor of Arts or Science (Required) with 3+ years' experience in healthcare management or healthcare education with education Specialization Nursing

• Master of Arts or Science (preferred)

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. REQNUMBER: UPHS-INFOR-205323