Regulatory Readiness Program Manager

** Job Profile*
* ** Summary
* * This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards.  In addition, this role focuses on performing the following Performance Improvement/Quality duties:
Identifies and executes performance improvement and quality opportunities across the enterprise, enabling successful transformations and driving cost savings, process and product quality, and achievement of business goals. Responsibilities also include partnering with business leaders to provide expert insight on existing processes and procedures, applies process improvement methodologies to achieve PI/Quality objectives, and builds process improvement capabilities.  A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  

The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.
A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.  Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.
** Job Overview
** This position leads efforts to ensure continuous organizational compliance and ongoing survey readiness with clinical quality and patient safety standards and regulations required by The Joint Commission (TJC), Massachusetts Department of Public Health (DPH), Center for Medicare and Medicaid Services (CMS) and other regulatory agencies as needed. In this role, the Manager proactively plans, implements, and coordinates continuous improvement and readiness efforts related to regulatory surveys.

Acts as a resource across the organization, overseeing complex projects to completion, facilitating teams engaged in regulatory readiness efforts, collaborating with leaders and staff, and is a role model and expert in team training, change management theory, and regulatory standards. This transformational leadership role focuses on the following:

- Continuous safety and quality improvement efforts and/or initiatives;

- Direct and collegial oversight and/or support specific to ongoing accreditation and regulatory requirements during and after the completion of on and off-site surveys;

- Subject matter expert in accreditation and regulatory requirements;

- Leads collaborative and collegial system wide rounding efforts to identify, recommend facilitate and support horizontally and vertically within the healthcare system to ensure continuous alignment with accreditation and regulatory requirements.
** Job Description
***
* Minimum Qualifications:

** 1. Bachelor’s degree.
2. Three (3) years of experience in healthcare leadership, Regulatory, Quality, and Patient Safety.
*
* Preferred Qualifications:

** 1. Master’s degree.
2. Certified Professional in Healthcare Quality (CPHQ).3. Five (5) years of experience in healthcare leadership, Regulatory, Quality and Patient Safety.
*
* Duties and Responsibilities:

** The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.
1. Serves as the organizational expert for The Joint Commission, DPH and CMS standards, regulations, and Conditions of Participation (CoPs). 2. Responsible for the interpretation and communication of regulatory requirements throughout the organization.  
3. Provides education and consultation to administrative and clinical leadership, staff and faculty regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.
4. Provides guidance and assistance to departments, sections, units, and programs regarding improvements needed to monitor and ensure compliance with regulations & standards for TJC,…