Regulatory Readiness Program Manager

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.

Hours: Full-Time 40 hours per week

Day Shift Monday-Friday (Fully Onsite)

Location: MelroseWakefield Hospital

Why Join Us?

• Competitive salaries

• 403(b) retirement plan with company match

• Clinical mobility tracks

• Free on-campus parking

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, DPH and CMS.

5. Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance.

6. Builds effective, supportive, and productive relationships with leadership, staff and faculty.

7. Facilitates development of tools, policies, procedures, and learning aids to promote compliance with standards.

8. Provides timely communication regarding new and revised standards and interpretations to administrative and clinical leadership, staff and faculty.

9. Works closely and builds effective working relationships with accreditation and regulatory agencies.

10. Responsible for all aspects of the plan to ensure continuous readiness with clinical regulatory and accreditation requirements.

11. Responsible for communication of the continuous readiness plan to leadership and key groups.

12. Works closely with Patient Safety/Risk Management, Quality Improvement and Data Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.

13. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.

14. Works with Patient Safety/Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events.

15. Stays current with new standards.

16. Develops, coordinates, and implements all aspects of the annual continuous readiness plan.

17. Performs ongoing assessment of the readiness plan.

18. Identifies needed improvements.

19. Prepares and implements action plans to achieve needed improvement and compliance.

20. Provides ongoing communication with regulatory agencies regarding survey and readiness activities.

21. Completes annual TJC application.

22. Supports response to agency requests for revision and corrective action plans.

About Melrose/Wakefield Hospital

Melrose/Wakefield Hospital and Lawrence Memorial Hospital of Medford are two campuses with one community in mind: the people of north suburban Boston. Melrose/Wakefield Hospital and Lawrence Memorial Hospital are distinguished by the range of high-quality clinical care and services. Our teams welcome everyone with hospitality and humanity. We focus on reducing health disparities through 40+ local health programs across a system of hospitals, urgent care locations, outpatient services, and community physicians.

Core to our values, Melrose/Wakefield Hospital's commitment to community is demonstrated by our many local health programs throughout our service area and participation in partnerships with community agencies and events, and education programs in more than 10 communities to support the wellness and health of our residents

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth-one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: