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Thomas Jefferson Univ Director Accreditation and Regulatory Affairs in Philadelphia, Pennsylvania

Jefferson Health delivers state of the art healthcare services to patients throughout the Delaware Valley and southern New Jersey. Jefferson (Philadelphia University + Thomas Jefferson University) provides more than 8,400 full and part-time students from nearly 40 states and 40 countries with 21st century professional education. Combined, we have over 30,000 employees.Jefferson Health, with 14 hospitals (seven are Magnet designated by the ANCC for nursing excellence) and 40+ outpatient and urgent care locations, offers a broad range of primary and complex, highly specialized care that touches the lives of more than four million patients annually. U.S. News .and.amp; World Report has ranked Thomas Jefferson University Hospital among the nation.and.#39;s best in eight specialties. Jefferson Health also includes the NCI designated Sidney Kimmel Cancer Center; it is one of only 70 such centers in the nation.Thomas Jefferson University has ten colleges and three schools that offer more than 160 undergraduate and graduate programs. Our University is dedicated to inter-professional and transdisciplinary approaches to learning that offer a vibrant and expandable platform for professional education. Through this unique model, we are preparing our students for current and yet to be imagined careers.As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.Educational / Training RequirementsBachelor.and.#39;s degree required in a healthcare discipline; masters preferred.Experience Requirements.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp; - At least 3 years related experience and/or training in healthcare/hospital accreditation and regulatory requirements..and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp; - Experience in working with acute care regulatory and standards compliance within the last five years..and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp; - Knowledge of processes, tools, and techniques for assessing and controlling organizations.and.#39; exposure to risks. Knowledge of governmental legislation and regulatory agencies that affect the organization..and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp; - Proven strong communication skills with various audiences throughout an organization..and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp;.and.nbsp; - Excellent relationship building experience.Primary ResponsibilitiesThe Director Accreditation .and.amp; Regulatory Affairs is responsible for ensuring continuous survey readiness and compliance with all accreditation standards across the continuum of care for the division, including TJUH, JHN, Methodist, JUP, and all owned and operated subsidiary businesses. The Director leads all site surveys and facilitates the development of multidisciplinary action plans to drive the desired outcomes. The Director is responsible for maintaining relationships with all external accreditation and regulatory agencies, maintaining familiarity with standards and new proposed regulations, and for educating divisional administrators, physicians, and staff to manage patient and/or organizational risk. The Director serves as a key resource to the TJUH System divisional leadership team and shall be champion of quality, safety, and operational excellence, proactively identifying organizational risk and deploying strategies to mitigate such risk.Essential FunctionsPerforms risk assessments and communicates findings to key personnel. Leads action plan development and performs audits to verify the desired outcomes have been achieved and sustained..and.nbsp;Participates in interdisciplinary committees and provides guidance and expertise on regulatory compliance in these forums, including environment of care, infection control, patient safety, etc.Provides education and consultation regarding regulatory and accreditation standards to manage