Regulatory & Accreditation Program Manager

Career At Lehigh Valley Health Network

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Interacts with internal leaders and external surveyors to sustain hospital licensure, accreditation, and certifications necessary to support organizational mission, vision, strategies, network goals, and strategic business objectives. Improves networkwide and department leader understanding of regulatory requirements serving as an innovative, strategic subject matter expert in the continuous readiness infrastructure. Cocreates, executes, evaluates, and adjusts short- and long-term team and departmental goals to proactively identify and rectify cited vulnerabilities. Cultivates a strengths-based culture of continuous improvement through the Plan, Do, Study, Act, process.

Job Duties

• Maintains expertise for all state Department of Health (DOH) Hospital Facilities regulations, The Joint Commission (TJC) accreditation and certification standards, and Centers for Medicare and Medicaid (CMS) Conditions of Participation assisting leaders with applicability across all healthcare programs. Synthesizes proposed and new standards for impact on all appropriate system wide programs.
• Conducts complex gap analyses across the network to proactively identify vulnerabilities of deficiency that could result in potential patient harm or interruption of accreditation or licensure through tracers, environmental consultation, and physician practice conversion assessments.
• Designs, plans, delivers, evaluates, and continually supports specialty certification and licensure needs for startup and ongoing programs such as Stroke, LVAD, Transplant, Ambulatory Surgery Centers, Behavioral Health, and Skilled Nursing. Serves as a subject matter expert and integral team member.
• Manages external regulatory and accreditation surveyors during formal onsite inspections for ongoing hospital licensure, occupancy, accreditation, and certifications of all campuses and off-site locations under the LVH license. Adeptly mitigates risk, navigates hospital policies, interacts with internal subject matter experts, and leads survey activities to ensure evidence of compliance is provided in a timely manner. Provides onsite survey support to other LVHN regions.
• Completes complex regulatory assessments of strategic initiatives for multifarious physician practice Hospital Outpatient Departments (HOPD) conversions, micro-hospitals, and renovation & expansion projects to provide clients and business partners status, results, and feedback for state licensure readiness of network strategic initiatives.
• Assists in preparing documents required for hospital licensure and accreditation for all hospital campuses and off site locations.
• Develops and delivers comprehensive educational and training programs necessary for ongoing and emerging licensure and accreditation based on a complete needs assessment.

Minimum Qualifications

Preferred Qualifications

Physical Demands

Lift and carry 25 lbs. frequent sitting / standing, frequent keyboard use,

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and / or social activities.