Position Summary:

Provides leadership to the organization relative to the Clinical Regulatory Compliance program which assures the implementation and oversight of clinical requirements developed by the Center for Medicare and Medicaid (CMS), the Department of Health (DOH), and The Joint Commission (TJC). The primary purpose of the Clinical Regulatory Compliance Program is to ensure that the policies and practices of the physician-based outpatient offices comply with the requirements of external organizations that regulate or accredit these offices, and to monitor that compliance. This function is distinct from the compliance program that operates under the authority of the Compliance Officer. This position provides leadership to include the assessment, development and evaluations of programs related regulatory compliance for staff throughout these offices.

Education, License, Certification:

Bachelor’s degree in nursing. Licensed nurse in the appropriate state

Experience:

Minimum of 5 years acute hospital experience. Prior experience in leadership/management desired. Demonstrated effective communications, critical thinking required.

Essential Functions:

• Assumes leadership regulatory responsibilities for the physician-based offices including:

a. Goal setting, developing monitoring tools, status reporting

b. Utilizes data for decision-making and strategic planning

• Prepares reports to regulatory agencies on a timely basis

a. Submits required reports to external agencies

b. Develops corrective actions as required

c. Monitors and reports on the implementation of corrective action plans

• Responsible for assuring that the physician-based offices comply with CMS, DOH and TJC requirements

a. Ensures that physician-based office leadership is aware of all regulatory requirements and findings (if necessary)

b. Ensures that corrective action plans are developed and implemented to meet new requirements and findings (if necessary)

c. Ensure that newly implemented processes are integrated into ongoing management and operational activities and that they are effective

d. Works in tandem with hospital regulatory leadership to standardize regulatory processes across the Guthrie system

e. Keeps physician-based office leadership and administration (including the Board of Directors) informed of regulatory findings and action plan progress via formal and/or informal reports on a regular basis

• Demonstrates the ability to be a person of interest

a. Builds trust

b. Provides leadership for implementing changes and/or performance improvement efforts

c. Creates a work environment that enhances employee, patient and provider satisfaction

d. Sets performance expectations and maintains high standards of performance

• Assists in facilitating committees, teams and workgroups for performance improvement activities

• Supports medical staff initiatives

• Assists in project development and management

• Works collaboratively with regional regulatory hospital leaders to operationalize electronic health record changes (i.e., orders, documentation fields/screens) that are consistent with clinical regulations and Guthrie policies

Other Duties:

1. This description is not intended to be all-inclusive. Other duties may be assigned, as necessary.

2. Travel is required.

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.