NorthShore

Program Manager, Regulatory and Accreditation

NorthShore • $97K — $150K *
Glenview, IL 60025In-Person
Healthcare
5 - 7 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Bachelor's Degree required
  • 5+ years in a clinical setting
  • 3+ years in quality, risk management, or regulatory/accreditation role
  • Familiarity with TJC, CoP, IDPH, EPIC, and healthcare workflows
  • Excellent written and presentation skills

Responsibilities

  • Lead regulatory activity preparation across entities
  • Develop compliance strategies with senior leadership
  • Oversee regulatory reporting with quality departments
  • Lead development of responses to accreditation bodies
  • Assist with accreditation survey readiness and standards interpretation
  • Educate organizational leaders on regulatory issues
  • Monitor regulatory changes and evaluate compliance needs

Benefits

  • Premium pay for eligible employees
  • Career Pathways to encourage professional growth
  • Various Medical, Dental, and Vision options
  • Tuition Reimbursement
  • Free Parking at designated locations
  • Wellness Program Savings Plan
  • Health Savings Account Options
  • Retirement Options with Company Match
  • Paid Time Off
  • Community Involvement Opportunities
Full Job Description
Hourly Pay Range:
$46.79 - $72.52 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position Highlights:
  • Position: Program Manager, Regulatory/Accreditation
  • Location: Glenview, IL
  • Full Time: 40 hours/week
  • Hours: Monday-Friday, 8:00a-4:30p
  • Required Travel: To other Endeavor locations


A Brief Overview:
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.

What you will do:
  • Lead preparation for regulatory activities at assigned entities, departments, business line and/or institutes. Work collaboratively with content area experts in the organization to ensure a continuous state of readiness throughout the organization.
  • Develop, in collaboration with assigned entities, departments, business line and/or institutes senior and executive leader on compliance strategies and tactics.
  • Provide oversight to required entity regulatory reporting in conjunction with quality and other departments.
  • Lead assigned entities' development and monitoring of responses to the Joint Commission and IDPH related to Evidence of Standards Completion (ESC) or other post survey activity.
  • Assist system accreditation and regulatory activities, including survey preparation and readiness assessments.
  • Assist with interpretation of standards and regulations, and serves as secondary point of contact for accreditation bodies.
  • Assist AVP in providing education for the organization leaders regarding regulatory and accreditation issues. Identifies learning needs and opportunities and researches training content and methods in collaboration with key areas impacted.
  • Responsible for monitoring regulatory websites for new information and new or revised standards, collaboratively evaluating compliance towards those changes and is instrumental in the development, assessment and achievement of organization readiness.
  • Lead readiness efforts at assigned entities, departments and/or institutes.
  • Lead standardization or regulatory workflows associated with assigned system policy and departments (eg 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 Tracer & 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 and other regulatory requirements.
  • Other duties as assigned.

What you will need:
  • Bachelors Degree Required
  • 5+ Years 5 Years experience in a clinical setting.
  • 3 Years 3 Years experience in quality, risk management, or regulatory/accreditation role.
  • Knowledge: 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.
  • Skills: 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.
  • Abilities: 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.
  • BLS - Basic Life Support (CPR and AED) - American Heart Association (AHA) Required And
  • Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Preferred Or
  • Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety (CBPPS) CHRM, CPPS, or CQP preferred Preferred


Benefits (for full and parti-time positions):
  • Premium pay for eligible employees
  • Career Pathways to Promote Professional Growth and Development
  • Various Medical, Dental, and Vision options
  • Tuition Reimbursement
  • Free Parking at designated locations
  • Wellness Program Savings Plan
  • Health Savings Account Options
  • Retirement Options with Company Match
  • Paid Time Off
  • Community Involvement Opportunities


About NorthShore

NorthShore Careers

There has never been a better time to explore the diverse job opportunities at NorthShore, a leader in fostering professional growth and innovation in the industry.

Work You’ll Do

Join NorthShore’s dynamic team to assist some of the most respected companies in navigating their paths to digital mastery and operational excellence. Elevate industries and transform business processes with the brightest minds at NorthShore. This company stands at the forefront of technology, combining industry expertise with a commitment to digital innovation. Lead with a distinct advantage in the marketplace, harnessing NorthShore’s unique blend of technology insight and deep industry knowledge. Engage with a global network of business and technology advisors dedicated to guiding clients through their transformation journeys. Collaborate with a robust team of professionals, making NorthShore a powerhouse of knowledge and capability in the tech industry.

Introducing the NorthShore Business Advisory Group

This group is at the helm of building a leading advisory team, guiding well-known companies worldwide through their digital transformation challenges with cutting-edge solutions.

Innovate at Work

Be part of NorthShore’s extensive network of experts, where innovation meets deep industry expertise and digital strategy.

Drive Innovative Solutions

Deliver targeted, innovative solutions that leverage the most trusted enterprise platforms, backed by a wealth of consulting experience and a commitment to forward-thinking.

Join a Stellar Team

Engage in projects utilizing a wide array of Microsoft technologies, and leverage the combined capabilities, global reach, and collaborative spirit of NorthShore’s team.

Future-Proof Your Career

Advance your career with NorthShore, where the opportunities for professional development are vast, supported by unparalleled training, development programs, and certification support.

Explore Opportunities

Discover how NorthShore leads companies like EcoSolutions towards sustainable practices with advanced predictive analytics, enhancing operational efficiency and reducing environmental impact.

The NorthShore Edge

NorthShore’s combined service capabilities and global reach enable clients to tackle disruption and lead industry transformations effectively. Clients globally turn to NorthShore for innovative strategies and solutions that drive growth and success in the digital age.

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Learn more about NorthShore
Size
11 employees
Industry
Business Services
* Ladders Estimates

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