Regulatory Readiness Program Manager

Job Profile Summary

Job Profile and Summary — This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. It involves performing Performance Improvement/Quality duties, identifying and executing opportunities across the enterprise to enable transformations, drive cost savings, improve process and product quality, and achieve business goals. Responsibilities include partnering with business leaders to provide expert insight on existing processes, applying process improvement methodologies to achieve PI/Quality objectives, and building process improvement capabilities.

This is an individual contributor role that may direct other 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 gained through advanced education. This is a senior-level role that requires advanced knowledge of the job area, typically obtained through advanced education and work experience.

Typical responsibilities include managing projects/processes, working independently with limited supervision, coaching and reviewing the work of lower-level professionals, and resolving difficult or complex problems.

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. The Manager proactively plans, implements, and coordinates continuous improvement and readiness efforts related to regulatory surveys.

It acts as a resource across the organization, oversees complex projects to completion, facilitates teams engaged in regulatory readiness efforts, and collaborates with leaders and staff. It 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-site and off-site surveys;
• Subject matter expert in accreditation and regulatory requirements;
• Leads collaborative 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.

Minimum Qualifications:

Preferred Qualifications:

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.