Regulatory Compliance Manager

Be a part of a world-class academic healthcare system at UChicago Medicine as a Regulatory Compliance Manager with our Clinical Compliance department. This hybrid position requires travel to our Chicagoland sites as needed, at times without advance notice.

The function of this position is to provide on-going support, instruction, and facilitation to operations across UChicago Medicine Health Care System to meet and exceed all patient care related regulatory agency standards, including but not limited to: Joint Commission, DNV, Centers for Medicare and Medicaid Services, Illinois Department of Public Health, College of American Pathologists, and the Chicago Department of Public Health, Indiana Department of Public Health et al. The Manager leads and participates in the development, implementation, and promotion of compliance activities to ensure appropriate and safe delivery of patient care and sustained compliance with regulatory standards. This position works collaboratively with the Director of Regulatory Compliance to maintain compliance oversight over all entities of the UChicago Medicine Health Care System through licensure and accreditation agreements.

Essential Job Functions

• Works collaboratively with Director of Regulatory Compliance to provide on-going oversight, support, instruction, and facilitation to all aspects of UChicago Medicine Health Care System to meet and exceed all patient care related regulatory agency standards, including but not limited to: DNV, Joint Commission, Centers for Medicare and Medicaid Services, Illinois Department of Public Health, College of American Pathologists, Chicago Board of Health. Excluded from the list are regulations focused on areas other than patient care processes, i.e. Department of Labor, zoning and construction codes, financial regulations, etc. 
• Monitor and disseminate standards, regulations, articles, etc. to the appropriate departments within UChicago Medicine Health Care System
• Leads and participates in the development, implementation, and promotion of compliance activities to ensure appropriate and safe delivery of patient care and successful completion of accreditation surveys and inspections
• Maintains a program philosophy of “Constant State of Readiness” and demonstrates sustained compliance with standards
• Serve as a liaison to regulatory agencies and accreditation bodies including on-site facilitation of any scheduled or for cause survey process
• Provide documentation and other information as requested by regulatory and accrediting bodies
• Maintain and organize all documentation in support of agency visits through communication, preparation, scheduling, reporting: manage all agency site visits and follow-up reports, activities, and historical files
• Recommend potential appeals or other follow-up actions, including implementations for all plans of correction. Participates in Emergency Management/HICS planning, drill, and responses
• Works collaboratively with Director to support the UChicago Medicine Health Care System Policies and Procedures process
• Develops and maintains a robust process to ensure timely review and development of policies
• Works collaboratively and participates in the following across the enterprise:

1. Root Cause Analysis
2. Committees (Medication Safety, Medical Executive, Quality, Infection Control et al)

• Performs other duties assigned by the Director

Required Qualifications

• Masters or B.S in a health-related field, or equivalent experience
• Hospital experience of at least 3-5 years in a clinical or administrative role with specific experience in dealing with patient safety, risk management, compliance, and/or quality
• Working EMR experience, in the use and build of reports to drive quality, patient safety and compliance
• Health Informatics experience, preferably with Epic
• Working knowledge of Joint Commission, DNV, HFAP and CMS standards
• Excellent oral, and interpersonal written communication skills, poise in teaching and consulting
• Strong organizing and data management skills, including word processing, spreadsheets, data base and graphics to design and implement monitoring and evaluation tools
• Fluent in the use of Microsoft Word, Excel, Smartsheet
• Advanced experience with Epic and the ability to build and run reports directly from Epic 

Position Details

• Job Type/FTE: Full-time
• Shift: Days
• Job Location: Hyde Park
• Unit/Department: Clinical Compliance
• CBA Code: Non-Union 

We’ve been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment… with patients and with each other. We’re in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you’d like to add enriching human life to your profile, UChicago Medicine is for you. Here at the forefront, we’re doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at: UChicago Medicine Career Opportunities.

UChicago Medicine is an equal opportunity employer.  We evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status and other legally protected characteristics.

Must comply with UChicago Medicine’s COVID-19 Vaccination requirement as a condition of employment. If you have already received the vaccination, you must provide proof as part of the pre-employment process. This is in addition to your compliance with the Flu Vaccination requirement as well. Medical and religious exemptions will be considered consistent with applicable law. Lastly, a pre-employment physical, drug screening, and background check are also required for all employees prior to hire.