Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Assists LVHN in achieving regulatory and accreditation compliance by providing assessment, consultation, facilitation, readiness strategies and performance improvement leadership and support in order to maintain state licensure, federal certification, accreditation, and applicable disease-specific certifications for network entities. Creates a partnership with leaders enabling them to understand regulatory requirements and to develop strategies within their departments to achieve and maintain ongoing regulatory readiness and compliance.

Job Duties

• Implements the regulatory readiness program by completing ongoing patient tracers and mock regulatory occupancy/licensure surveys to identify potential compliance issues and areas of vulnerability, and provide education to staff.
• Initiates and facilitates performance improvement projects to resolve regulatory, accreditation and certification compliance issues identified through onsite/offsite survey activity, internal regulatory queries, and proactive risk assessments.
• Leads gap analyses and brings stakeholder groups to consensus on strategies and/or actions necessary to operationalize new accreditation and regulatory requirements.
• Facilitates onsite regulatory and accreditation survey visits, inclusive of surveyor escort, surveyor request research and response, and ongoing timely communication with organizational leaders.
• Coordinates completion of post-survey corrective action activities, inclusive of development and documentation of plans of correction, audit monitoring system, and evidencing of sustained improvements.
• Provides consultation to colleagues by providing interpretation and guidance of regulatory and accreditation requirements, with a position specific focus on hospital, home health, hospice and behavioral health, to assure implementation and adherence to standards.
• Manages clinical disease specific certifications as a certification subject matter expert and integral team member to assure ongoing compliance and enhanced clinical quality and safety.
• Assesses new service initiatives and advises project teams on regulatory requirements, areas of vulnerability, and strategies to attain licensure.
• Provides ongoing support to other LVHN regions for survey activity and/or other compliance needs.
• Plans and provides education through development of publications and educational offerings to support regulatory/accreditation readiness initiatives and to educate staff on accreditation and licensure standards and regulations.

• Bachelor’s Degree Clinical area or health-care related field
• 5 years Acute care hospital nursing, patient-care, Home Care, Hospice or other hospital operations experience
• Extensive team facilitation and project management skills.
• Proficiency in Microsoft Suite: (Word, Excel, PowerPoint, Outlook).
• Ability to solve problems and build consensus
• Highly organized with the ability to work well with people
• Ability to work with highly sensitive and confidential information

• Master’s Degree Health-care related field
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Influenza vaccination and COVID-19 Vaccination is required for all colleagues unless medically contraindicated or due to a bona fide religious belief or practice. Applicants possessing a medical marijuana card will not be considered for safety sensitive positions.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

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