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Seeking Breakthrough Makers

Children’s Hospital of Philadelphia (CHOP)—named America’s 2022 Best Large Employer by Forbes—offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.
At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care—and your career.

CHOP’s Commitment to Diversity, Equity, and Inclusion

CHOP is committed to building an inclusive culture where employees feel a sense of belonging, connection, and community within their workplace. We are a team dedicated to fostering an environment that allows for all to be their authentic selves. We are focused on attracting, cultivating, and retaining diverse talent who can help us deliver on our mission to be a world leader in the advancement of healthcare for children.
We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.

A Brief Overview
Assist the Accreditation Manager in maintaining a continuous state of preparation for all accreditation and regulatory surveys. Also assist in developing plans of action and coordinating follow up activities from surveys. Demonstrate the application of clear, accurate and current understanding of Joint Commission, Department of Health, Office of Mental Health & Substance Abuse Services (OMHSAS), Community Behavioral Health (CBH), and CMS requirements, to allow accurate and timely identification of problem areas. Review publications related to accreditation standards and survey preparation and other materials provided by the Accreditation Manager and demonstrate the application of this material to CHOP culture and operations.

What you will do

• Assist the Accreditation Manager in the coordination activities to maintain continual compliance for Joint Commission(JC), Pennsylvania and New Jersey DOH surveys and/or unannounced, Office of Mental Health & Substance Abuse Services (OMHSAS), Community Behavioral Health (CBH), visits and CMS Validation surveys.
• Develop a working understanding of the standards in the Joint Commission Comprehensive Accreditation Manual for Hospitals, Joint Commission Behavioral Health and Home Care standards as well as all applicable CMS Conditions of Participation and PA/NJ Department of Health regulations, OMHSAS and CBH regulations, and continually maintains knowledge base in an ever changing regulatory environment.
• Provide consultation on JC, PADOH, OMHSAS, CBH, and CMS standards interpretation upon request. Support clinical staff and executive staff, as well as managers in developing and/or refining systems that support compliance with standards of accrediting bodies, as well as applicable law and regulation. Provide consultation through participation on assigned ECMS committees and special projects as needed.
• Facilitate the completion of the required self-assessments of standards and regulations as directed by accrediting bodies such as JC and CMS.
• Coordinate and facilitate the PADOH, NJDOH, CMS, OMHSAS, CBH complaint and occupancy surveys for new construction, new services and unannounced patient complaint surveys.
• Facilitates the coordination of communication of policy, procedure, and practice changes across the organization to ensure the organization is kept apprised of current practice changes and upcoming streams of work.

Education Qualifications

• Bachelor's Degree Required
• Bachelor's Degree Health-related field Preferred

Experience Qualifications

• At least three (3) years relevant experience with a focus in behavioral health Required
• At least one (1) year clinically focused work writing policies or guidance documents, promoting patient safety principles and/or clinical regulatory experience. Preferred

Skills and Abilities

• Proficient with Internet, MS Office and other computer applications required. (Required proficiency)
• Familiarity with Microsoft Teams and One Drive preferred. (Preferred proficiency)
• Facilitation skills to successfully advance the documentation of processes involving complex teams. (Required proficiency)
• Strong writing, editing and proof-reading skills required. (Required proficiency)
• Ability to use personal judgment and initiative to develop effective and constructive solutions to barriers to policy development /revision activity and process. (Required proficiency)
• Ability to manage multiple priorities. (Required proficiency)
• Excellent interpersonal & communication skills; ability to work independently or as part of a team (Required proficiency)

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, professionals working onsite—at any CHOP location, for any portion of time—must be vaccinated for COVID-19. Learn more.

CHOP also requires employees who work in patient care buildings to receive an annual influenza vaccine. Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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