Job Summary

Responsible for coordinating a platform-wide Regulatory Performance Improvement program to monitor compliance to regulations and standards governing the operation of hospitals and the delivery of patient care services, as established by federal and state mandates, CMS, accreditation bodies as well as internal policies and procedures. Responsibility involves on-going education and consultation with department leaders, operations managers and administrators to keep them advised of current requirements and changes; monitoring hospital-wide compliance on an on-going basis; ensuring proper procedures for reporting and documenting conformance to standards; and developing methods for corrective action when problems are identified. Provides direction and leadership to the platform Performance Improvement program. Manages complex projects, facilitates change and regulatory improvements in quality and safety.

Job Duties

• Provides employee supervision and supports the daily operations of activities for the Regulatory Performance Improvement Department.
• Develops procedures for implementing and monitoring compliance to regulations in conjunction with Director, Leadership, physicians, nurses and other staff.
• Participates in recruitment and retention of all professional and paraprofessional staff.
• Supports Regional Director with staffing plans to support the department including position descriptions, performance evaluations, action plans, employee goal setting, hiring, promotion and disciplinary actions
• Ensures, in conjunction with Director, that all administrative policies and procedures pertaining to Regulatory Performance Improvement are current and reviewed annually.
• Provides education and consultation on Proactive Risk Assessment and FMEA methodology.
• Contributes to the development of quality reports to provide analytics for Division staff and our customers Participates in major survey preparation, and assists in development of plans of correction, implementation strategies, and continuing oversight Participates in Joint Commission Sentinel Event reporting process to identify Root Causes.
• Completes all submissions to the Joint Commission within required time frames.
• Active member of RCA team.
• Maintains knowledge of regulatory agencies' standards and regulations.
• Develops plans for platform and hospital mock survey activities.  Coordinates readiness rounds on inpatient and hospital based clinics in preparation for state and federal surveys.
• Leads preparation and planning for hospital PI Committee meetings with chairperson and other department staff.
• Assures confidentiality of information coming into and being disseminated out of the Regulatory Performance Improvement Department.
• Works collaboratively with Risk Management and Patient Safety Department and Infection Prevention and Control Department to assure compliance with related healthcare regulations.

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

• Hours: 8am to 4:30pm
• Travel: Limited within region
• Required experience: BSN with 2 yrs of supervisory experience

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At Geisinger, the caring that we provide to our patients and members also extends to you and your family. Our competitive compensation and benefits package helps you and your loved ones stay healthy, meet your financial goals and thrive professionally and personally.

• Benefits: Geisinger offers a comprehensive suite of healthcare benefits, including medical, prescription drug, vision, dental coverage and 401K. And with our healthcare benefits, you'll also receive care from one of the top innovative healthcare systems in the country. Our suite of benefits supports you and your family in a variety of ways, including coverage for same-sex or opposite-sex spouses, domestic partners and their children and stepchildren.
• Paid Time Off: Our generous paid-time-off packages allow you to take the time you need to travel, rest, and care for and reconnect with friends and family. We also offer paid military and parental leave.
• Diversity and Inclusion: We strive to create an environment where our patients, health plan members and employees can be their most authentic selves. Join one of our many Employee Resource Groups (ERGs). ERGs provide opportunities for all Geisinger employees to build internal and external networks and further develop professionally. ERGs are formed around common identities but are open to all employees.
• Tuition Assistance: Up to $5,000 tuition reimbursement: We offer tuition reimbursement towards both undergraduate and graduate degrees.(Part time and Full Time Positions only)

• Retirement: We contribute 5% of your salary to your retirement plan and offer auto-enrollment to make saving convenient for you.

Education

Bachelor's Degree-Nursing (Required)

Experience

Minimum of 2 years-Managing people, processes, or projects (Required)

Certification(s) and License(s)

Valid Driver's License - Default Issuing Body; Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania

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.