Company :Allegheny Health NetworkJob Description : 

GENERAL OVERVIEW:

Create a culture of continuous regulatory readiness through continual proactive risk assessment and mitigation efforts. Manage, oversee and coordinate all activities related to maintaining an ongoing state of regulatory compliance through proactive risk assessments and mitigation efforts. Manage and coordinate on-site investigations and surveys conducted by various regulatory and accrediting agencies. Manage the policy administration infrastructure to support the formulation, review, approval, and dissemination of ABC Hospital policies and procedures.                     

ESSENTIAL RESPONSIBILITIES:

Create a culture of continuous regulatory readiness through continual proactive measures. Educate all levels of staff, including managers, directors and senior leaders to regulatory requirements including regulations and standards in development. (20%)Conduct regular assessments through audits (formal and informal), mock tracers and mock surveys.  Respond to actual or potential noncompliance identified via these assessments by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the risk or deficiency; oversee ongoing monitoring to ensure sustained regulatory compliance. (20%)Support and participate in the Network continuous survey readiness effort: host mock surveys; participate in other hospitals mock surveys; participate in other hospitals investigations, inspections and surveys as appropriate.  (15%)Manage all aspects of investigations, inspections and surveys conducted by regulatory and accrediting agencies: prepare for and facilitate visits, ensuring appropriate oversight of the regulators/surveyors; respond to deficiencies by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the deficiency; oversee ongoing monitoring to ensure sustained regulatory compliance. (20%)Serves as the hospital's liaison with regulatory and accrediting agencies, including but not limited to: The Joint Commission, The PA Department of Health, OSHA, and the FDA. In this role, represent the hospital during surveys and hearings before regulatory agencies. (10%)Ensure that hospital policies and procedures are consistent with laws, regulations and standards; ensure compliance with hospital policies via education, auditing, communicating results of audits, ensuring corrective actions are taken by management staff and overseeing sustained compliance. (10%)Other duties as assigned. (5%)

QUALIFICATIONS:

Minimum

Bachelor's degree in healthcare, regulatory or compliance1 - 3 years work experience in the regulatory, accreditation or compliance field1 - 3 years supervisory experience3 - 5 years experience facilitating or coordinating investigations or surveys conducted by regulatory or accrediting agencies

Preferred

Master's degree in healthcare, regulatory or compliance3 - 5 years work experience in the regulatory, accreditation or compliance fieldCertified Joint Commission Professional

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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