Program Manager, Accreditation and Regulatory Compliance

Reporting to the Assistant Vice President Accreditation, Regulatory and Compliance, coordinates and serves as primary contact for system wide complex accreditation, certification and regulatory activities, including review of abuse allegations, survey preparation and readiness assessments for facilities within Endeavor Health.
 

Lead and support entity/business line compliance with The Joint Commission (TJC), the Accreditation Commission for Health Care (ACHC), Accreditation Association for Ambulatory Health Care (AAAHC), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid Services (CMS) and other State and Federal agencies. 

Position Highlights:

• Position: Program Manager, Accreditation and Regulatory Compliance

• Location: Evanston Hospital

• Full Time/Part Time: Full Time

• Hours: Monday-Friday, 8:00am-4:30pm

• Required Travel: travel to other locations may be required

What you will do:

• Lead readiness efforts at assigned entities, departments and/or institutes.

• Lead standardization or regulatory workflows associated with assigned system policies, workflows and departments (e.g., clinical contract reviews, supply chain, HIM, etc.)

• Co-lead abuse and key sentinel investigations with local or system leaders, ensure standardization of investigation. Documentation and follow-up.  Analyze trends and recommend opportunities for improvement.

• Manage oversight of tracers & Epic audit reports to support monitoring and reporting of regulatory compliance risk

• Support Policy Stat workflows at assigned entities, departments, and/or institutes

• Support regulatory audit and reviews to ensure compliance with provider-based rules, co-location rules, ADA, ACA and other regulatory requirements

What you will need:

• Education: Bachelor’s Degree. Preferred degree in a clinical or scientific area and master’s prepared.

• Certification: CHRM, CPPS, or CQP preferred. RN preferred.

• Experience:

  • 5+ years of experience in a clinical setting.

  • 3+ years of experience in quality, risk management, or regulatory/accreditation role.

• Unique or Preferred Skills:

  • Familiarity with TJC, CoP, IDPH, EPIC and hospital clinical and operational workflows, and admin functions. 

  • Commitment to staying current with evolving regulations, standard and best practices in healthcare.

  • Excellent written and presentation skills.

  • Managing accreditation/change projects, including timeliness, resource allocation and team coordination.

  • Data analysis and proficiency in MS Excel. Effective writing skills for policies, procedures and compliance reports.

  • Ability to collect, analyze and report data to demonstrate compliance. Ability to navigate complex regulatory and legal issues related to healthcare delivery. 

  • Ability to effectively communicate regulatory requirement and changes to all level of staff and leadership. 

Benefits:

• Career Pathways to Promote Professional Growth and Development

• Various Medical, Dental, Pet and Vision options

• Tuition Reimbursement

• Free Parking

• Wellness Program Savings Plan

• Health Savings Account Options

• Retirement Options with Company Match

• Paid Time Off and Holiday Pay

• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals – Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) – all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.  

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to “help everyone in our communities be their best”. 

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.