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Accreditation Manager

Company: The Children's Hospital of Philadelphia
Location: Philadelphia
Posted on: November 11, 2019

Job Description:

BUERGER - Buerger Center Ambulatory Care Req ID: 29051

Shift: Days

Employment Status: AF - Active - Regular - Full Time JOB SUMMARY

Responsible for the coordination of activities to maintain continual regulatory (CMS, DOH, and Joint Commission) readiness at CHOP, to include introducing new systems, coordinating surveys, measuring and reporting compliance, conducting mock surveys, and coordinating completion of improvement plans. Collaborates with Director on responding to inquiries and complaints from DOH, CMS and Joint Commission. Manages all accreditation personnel and collaborates with support staff to ensure the smooth operation of the department. JOB RESPONSIBILITIES

* Manages accreditation staff, policy staff and clinical coordinator (total FTEs 6).

* Manages activities to maintain continual compliance with Joint Commission, CMS and other clinical standards, by working in partnership with identified operational leaders. Acts as an internal consultant and maintains a working knowledge of changes to regulatory processes, and with key leaders, facilitates and supports the implementation of organizational changes in response to the changes.

* Manages accreditation staff, policy staff and clinical coordinator.

* Manages Joint Commission, Pennsylvania and New Jersey DOH occupancy and complaint surveys and/or unannounced visits. With the designated leaders, develops a plan and coordinates follow up activities from the survey.


Required Education: Bachelor s Degree

Required Experience:

* At least five (5) years of healthcare accreditation and regulatory experience with direct experience managing related systems and implementing Joint Commission, Department of Health, CMS or similar regulatory requirements.

* At least three (3) years experience of leading teams using Performance Improvement, Continuous Quality Improvement or Total Quality Management methods.


Preferred Education: Master degree

Preferred Licenses/certificates/registrations: Certified Joint Commission Professional CJCP ADDITIONAL TECHNICAL REQUIREMENTS

* Demonstrated leadership skills in working with teams to achieve the expected results while engendering cooperation, confidence and respect from leaders and staff at all levels of the organization.

* Capable of making significant decisions that will impact on the overall success of the organization, in collaboration with the Director, hospital and medical leadership and with the immediate team.

* Demonstrated experience in coordinating and implementing complex clinical projects in the healthcare environment.

* Excellent verbal and written skills.

* Advanced facilitation and interpersonal communication skills to provide effective consultation and collaboration and to maintain positive relationships with leaders and staff at all levels.

* Ability to organize and define problems, develop strategies, and carry out action plans while balancing the needs of a diverse group of customers.

* Advanced analytical skills to trend and analyze data.

* Demonstrated ability to work in a highly complex organizational environment.

* Ability to prioritize work and execute to meet deadlines while managing multiple priorities simultaneously and to assign work to team members .

* Demonstrated skills as a change agent; flexible thinker, with an ability to quickly adapt to a changing environment or changing external requirements while developing a spirit of enthusiasm about the changing requirements.

All CHOP employees who work in a patient building or who provide patient care are required to receive an annual influenza vaccine unless they are granted a medical or religious exemption.

Children\'s Hospital of Philadelphia is committed to providing a safe and healthy environment for its patients, family members, visitors and employees. In an effort to achieve this goal, employment at Children\'s Hospital of Philadelphia, other than for positions with regularly scheduled hours in New Jersey, is contingent upon an attestation that the job applicant does not use tobacco products or nicotine in any form and a negative nicotine screen (the latter occurs after a job offer).

Children\'s Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sexual orientation, age, religion, national or ethnic origin, disability or protected veteran status.

VEVRAA Federal Contractor/Seeking priority referrals for protected veterans. Please contact our hiring official with any referrals or questions.

CHOP Careers Contact

Talent Acquisition

2716 South Street, 6th Floor

Philadelphia, PA 19146

Phone: 866-820-9288

Keywords: The Children's Hospital of Philadelphia, Philadelphia , Accreditation Manager, Executive , Philadelphia, Pennsylvania

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