Manager of Regulatory Compliance

Manager of Regulatory Compliance

Signature Healthcare is southeastern Massachusetts’ premier local provider of quality, personalized medical services. We are comprised of the award‑winning not‑for‑profit Signature Healthcare Brockton Hospital;
Signature Medical Group (SMG), a multi‑specialty physician group of more than 150 physicians practicing in 18 ambulatory locations. We believe our distinctive Signature Healthcare team approach is the way healthcare should be: medical professionals across many locations communicating and collaborating, taking advantage of technologies and resources to make a difference in the lives and health of our patients.

Under the general supervision of the Vice President of Quality Resources, the Manager of Regulatory Compliance is responsible for overseeing organizational activities related to compliance with standards applied by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). This role involves interpreting licensure, regulatory, and accrediting requirements, assessing the organization’s current compliance, and providing direct support and consultative services to meet accreditation and regulatory standards.

The Manager develops and monitors action plans for continuous survey readiness and coordinates TJC compliance activities. Utilizing tracer methodology, the Manager organizes tracer activity across the organization to evaluate compliance with standards, identify areas for improvement, and support the development and evaluation of organizational action plans.

The manager collaborates across a matrixed system with various department leaders to develop and implement strategies for mitigating compliance‑related risks, thus ensuring effective risk management practices are in place. The Manager employs Failure Mode and Effects Analysis (FMEA) and other risk assessment methodology to identify potential failures in processes and procedures, assessing their impact and likelihood, and prioritizing risk mitigation efforts accordingly.

The role ensures that compliance activities and organizational policies promote and support health equity, addressing disparities in healthcare delivery and outcomes. Conducting detailed data analysis to identify trends, risks, and areas for improvement in regulatory compliance and patient safety, the Manager utilizes data to inform decision‑making and develop actionable insights related to accreditation and payor contracts.

The Manager prepares and, as needed, presents reports on compliance activities, trends, and outcomes to senior leadership and governing bodies, while also serving as the subject matter expert, consultant, and trainer on all compliance‑related activities within the organization to promote and support a culture of regulatory compliance and patient and staff safety.

This position requires experience in healthcare compliance, regulatory affairs, or a related field, a strong understanding of TJC and CMS standards and requirements, proficiency in data analysis and interpretation, and significant involvement in risk management. Excellent communication and interpersonal skills, strong organizational and project management skills, and the ability to manage multiple priorities and deadlines are essential for this role. The ability to build strong relationships within and across teams is a must.

680 Centre Street, Brockton, MA

Quality Resources

Full‑time 40 hour/week

• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
• Commits to recognize and respect cultural diversity for all customers (internal and external).
• Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
• Maintain current knowledge of DPH (Department of Public Health), CMS, Joint Commission, and other regulatory standards and regulations. Participate in developing, implementing, and leading strategies to comply with identified standards and regulations.
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