Regulatory and Accreditation Specialist

3 months ago

Bala Cynwyd, United States Pennsylvania Medicine Full time

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:

  • The Regulatory and Accreditation Specialist establishes and implements regulatory standards and processes, including improving and maintaining regulatory clinical documentation standards.The Specialist will facilitate survey readiness and monitor for ongoing clinical documentation compliance.The Specialist will support an organization-wide system for improving clinical documentation in the medical record by promoting clinicians for complete and accurate documentation that aligns with federal, state, and Joint Commission (TJC) accreditation standards. The Specialist will guide improvement and develop plans for sustaining the improvements and compliance.The Specialist coordinates documentation review for ongoing survey readiness, assists with onsite surveys across home care, infusion, and hospice departments, provides education,and accepts other duties as assigned.This individual is accountable for collecting, analyzing, and interpreting audit findings, contributing to evaluating the regulatory compliance trends, and providing leadership, management, and facilitation of clinical documentation audit teams. The Specialist strives to become an expert resource to Penn Medicine at Home and related entities.The Specialist utilizes presentation, general instruction, and compliant query discussion to instruct the clinical teams in appropriate documentation as CMS, DOH regulations, and TJC accreditation standards suggested.Working under the leadership of the Director of Regulatory and Patient Affairs and close association with the Penn Medicine at Home leadership and clinical teams, including hospice, home health, and home infusion, develops and utilizes compliance audit tools and inquiry to ensure accurate review of clinical documentation and the development of follow up measures.
Responsibilities:
  • Provide direct support to the directors/managers/leaders of various departments striving for continuous survey readiness.
  • Coordinate actual and mock survey activity
  • complete & facilitate tracer activity as required during the survey process by surveyors and department leaders.
  • Coordinate direct review of patient records of care team documentation with consideration of regulatory and accreditation standards.
  • Provide clinical care teams with ongoing education and training on current trends in documentation, including but not limited to regulatory and accreditation standards.
  • Facilitate interdisciplinary teams and committees to drive compliance and readiness at Penn Medicine at Home (PMAH) and related entities.
  • Participate as a management liaison/representative in entity-based staff meetings, staff-focused formal presentations/discussions, and daily/team instruction to reinforce regulatory documentation requirements.
  • Demonstrate as an expert clinical data specialist in reviewing charts, truth, and precision in documentation expectation and guidance such towards federal, state regulatory, and accreditation standard-specific documentation requirements.
  • Ensure timely and accurate completion of a review of charts for PMAH entities and distribution of data to PMAH leadership.
  • Utilize technical and analytical skills to coordinate and facilitate data retrieval and/or information collection, analysis, and distribution.
  • Lead and participate in special projects as directed.
  • Assist with mentoring department staff, including employee orientation, performance management, development, training, and continuing education needs for staff.
  • Collaborate with team members and PMAH leadership to apply innovative systems thinking to engage in systematic, evidence-based problem-solving and decision-making to promote effective changes within PMAH.
  • Identify areas where additional training and education are needed to assure ongoing survey readiness and compliance. Develop and educate all entities and teams to ensure continual survey readiness and regulatory compliance.
Credentials:
  • Registered Nurse - PA (Required)
  • Cert Prof in Healthcare Qlty
  • Certified Professional Healthcare Quality (CPHQ)
  • LEAN or SSBB
  • Lean and/or Six Sigma certification

Education or 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.

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