**General Summary**

Provides direction and leadership by coordinating activities designed to achieve and maintain compliance with the PA Department of Health, entity/area accreditation organizations, CMS Conditions of Participation, and the Department of Human Services regulations for several assigned WellSpan entity/ies and/or area(s). Performs a variety of audits, analysis of the data as well as ensures compliance with regulatory audits. Acts as coordinator for on-site surveys and works in collaboration with others to facilitate system process and outcome improvements. Working with clinical teams and entity operational staff, determines root cause for identified defects and deficiencies and prepares standard work and policy recommendations as appropriate. Liaises with Medical Staff Services team members who work with the same WellSpan entity/ies and/or area(s) in the areas of credentialing, clinical privileges, and medical staff governance. For staff who support specific Wel...