Job Summary

Responsible for the oversight and direction of the system's comprehensive program for accreditation, certification and regulatory activities. This includes, planning, execution, monitoring, and evaluation of assessment activities for ensuring continual compliance. Serves as the leader and expert resource for regulatory/accreditation and licensure standards and sets expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements.

Job Duties

• Implements and develops quality and performance programs across all Geisinger sites.
• Leads and coordinates a performance improvement program in accordance with the regulatory standards.
• Evaluates existing operational processes and makes recommendations on improvements to increase, quality, safety, productivity, efficiency and effectiveness.
• Collaborates with the Institutes and Medical Staff members, Geisinger leaders and staff to design and implement measures, facilitate assessments, and lead processes to improve quality and safety outcomes as related to priorities aligned with strategic plans, annual objectives and regulatory or accreditation requirements.
• Provides consultation and education to relevant leaders and committees to ensure translation of standards and requirements into policies and terms or processes meaningful to the staff to ensure ongoing compliance.
• Directs the compilation of data and preparation of reports and recommendations for effective performance improvement related to clinical services and patient care.
• Assists in the identification of quality issues or potential problems throughout the system and assists in the development of criteria and methods for prioritization and analysis.
• Serves as a resource to ensure compliance with regulatory requirements.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details

Hybrid position which will require travel to all Geisinger licensed facilities within the Geisinger footprint

Extensive knowledge of all regulatory standards and agencies (CMS/JCAHO/DOH)

Education

Bachelor's Degree-Healthcare Related Degree (Required)

Experience

Minimum of 5 years-Related work experience (Preferred)

Certification(s) and License(s)

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

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