Job Details

Director, Regulatory Affairs is responsible for the development, implementation, and evaluation of the TJUH, Inc. for regulatory and accreditation program. The duties include working within a matrix management environment to ensure compliance with all regulations and standards promulgated by CMS, Joint Commission, CARF, the Department of Health of the Commonwealth of Pennsylvania, the Department of Health of New Jersey and other regulatory bodies that may be present themselves from time to time.

Job Description

• Interact with co-workers, visitors, and other staff consistent with the values of Jefferson
• Lead and manage the regulatory affairs program.  Guide and delegate to subordinate team members and lead them to achieve defined goals and objectives, supporting broad organizational initiatives.
• Lead DOH, CMS, Joint Commission and CARF on-site and virtual survey activities which may occur at any time of the day.  Plan, organize, and oversee site visits, mock surveys and mock accreditation sessions designed to support preparedness for accreditation and surveys. Develop and lead all regulatory preparedness activities.
• Monitor and advise units and off-site locations across the organization to ensure consistent compliance with the on-going and new regulatory and accreditation requirements.
• In collaboration with the team, prepare for all scheduled and unscheduled visits by licensure and accreditation bodies.
• Work with stakeholders to respond to complaints that are brought forward by regulatory bodies and Insurer Quality Departments. Lead corrective action plan development and support implementation as needed.
• Lead the completion of any survey follow-up activities, such as providing evidence of standard compliance. Monitor completion of required follow-up audits.
• Lead efforts to convert off-site locations to hospital-based locations per strategic plan.  Work with the Planning, Design and Construction team to track and foster timely completion of all occupancy projects while ensuring compliance with all FGI guidelines and other regulatory requirements.
• Provide expert analysis of regulations and interpretive guidance and articulate the intent and value of the regulations to stakeholders.  Consult with hospital attorneys when legal guidance or interpretation is needed.
• Advise and support compliance efforts for programs that have or seek professional accreditation and certification.
• Guide and collaborate with leaders, administrators and departmental staff representatives in relation to regulatory and accreditation compliance activities. Work collaboratively with the medical staff, risk, safety, quality, infection control and patient experience departments to align efforts and maximize efficiency with regulatory compliance.
• Attend daily TJUH Inc safety huddle or delegate the task to someone on the regulatory team, to provide regulatory support and input.
• When needed, oversee the development of corrective action plans in collaboration with other team members

Education and Experience:

Master’s degree required in related field. Master’s degree in clinical / allied health field preferred

At least three years of management experience and at least 3 years of experience working with State and Federal hospital regulations.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University Hospitals, Inc.

Primary Location Address

111 S 11th Street, Philadelphia, Pennsylvania, United States of America

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. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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