Signature Healthcare, MA · 2 months ago
Manager of Regulatory Compliance
Brockton, MA
Full-time
Onsite
Mid, Senior Level
3+ years expSignature Healthcare is Southeastern Massachusetts’ premier local provider of quality, personalized medical services. The Manager of Regulatory Compliance is responsible for overseeing compliance with standards set by The Joint Commission and CMS, developing strategies for risk management, and ensuring the organization meets accreditation requirements.
Health CareHospitalMedical
Responsibilities
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
Incorporate process improvement techniques (PDCA, Lean) into regulatory compliance activities
Act as a champion for the organization’s Culture of Safety program
Lead and coordinate The Joint Commission Steering Committee
Coordinate The Joint Commission Tracer Team process, ensuring active participation of leadership and management
Facilitate Tracer Team feedback to appropriate individuals
Maintain The Joint Commission SigNet page and lead proactive risk assessments and risk mitigation initiatives
Coordinate all communications between TJC and SHBH, including the Electronic Application, Intra-Cycle Monitoring Profile, the annual TJC invoices, TJC Survey, TJC Complaints, and updates any SHBH changes
Continuously review TJC website for educational resources, FAQs (Frequently Asked Questions), and standard updates. Review TJC Perspectives and educate appropriate individuals regarding future changes
Maintain awareness of the CMS Conditions of Participation (COPs) to ensure SHBH compliance
Actively participate in designated hospital-wide committees as appropriate
Participate in outside professional organizations, committees, and functions as a hospital representative
Develop, implement, and maintain policies related to regulatory standards
In partnership with Quality leaders, help define and execute Quality program performance improvement strategies
Develop and implement quality improvement initiatives to enhance patient outcomes and satisfaction
Analyze clinical data to identify areas for improvement and monitor progress towards quality goals
Facilitate multidisciplinary teams to drive quality improvement projects and initiatives
Ensure compliance with regulatory standards and accreditation requirements related to quality and safety and support teams and individuals to do the same
Conduct root cause analyses and implement corrective actions to address identified issues
Collaborate with healthcare providers and staff to implement evidence-based practices and clinical guidelines
Lead quality improvement training and education sessions for healthcare professionals
Participate in performance measurement and reporting activities to track quality metrics and outcomes, especially within the Quality Resources and Infection Control Departments
Utilize Lean and other process improvement methodologies to streamline workflows and eliminate waste
In concern with other organizational efforts, engage patients and families in quality improvement efforts through feedback mechanisms and patient engagement strategies
Performs other duties as assigned
Qualification
Required
Experience in healthcare compliance, regulatory affairs, or a related field
Strong understanding of TJC and CMS standards and requirements
Proficiency in data analysis and interpretation
Significant involvement in risk management
Excellent communication and interpersonal skills
Strong organizational and project management skills
Ability to manage multiple priorities and deadlines
Ability to build strong relationships within and across teams
Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization may exist
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
Ability to reasonably make appropriate judgment in communications and actions with patients, physicians, other associates, outside agencies, and vendors
Knowledge of federal and state regulations and standards, specifically The Joint Commission (TJC), DPH, and CMS Conditions of Participation
Competency in research and investigation techniques with the ability to interpret data, prepare reports, and propose solutions to performance gaps and quality and safety issues
Proficiency with word processing, spreadsheets, database software, and office products
Ability to independently prioritize work projects and comply with established/required deadlines
Willingness to understand DEI frameworks to bring best practice solutions to drive organizational strategy
Exceptional human leadership capability – listening, being curious, and willingness to learn from others
Effective change management skills to implement workplace programs grounded in the principles of Patient Safety, RBC (Relationship-based Care), and DE&I (Diversity Equity and Inclusion)
Excellent written and verbal communication skills to clearly articulate ideas and decisions to stakeholders
Ability to work collaboratively with a wide array of colleagues and clients to integrate Patient Safety, RBC, and DE&I best practices into daily operations
Demonstrated ability to manage conflict and advance relationships and conversations
Effective project management, program administration, and organizational skills
Strong analytical skills to gather, interpret, deliver information, and make decisions from data
Ability to multi-task, manage multiple constituents and multiple deadlines
Passion for learning and a mindset of continuous improvement
Strong strategic thinking aptitude, management experience, and analytic orientation
Expert-level knowledge of the healthcare environment, strategic planning, change, and project management
Excellent interpersonal skills with the ability to navigate highly complex projects through a consensus-driven environment
Excellent organizational and time management skills with the ability to prioritize projects in connection with strategic priorities
Excellent written and oral communication skills with the ability to deliver presentations to a wide variety of audiences
Ability to interact regularly and confidently with C-Suite executives
Ability to convert project and stakeholder needs into meaningful frameworks and provide guidance to key stakeholders
Ability to interact and influence organization-wide and work collaboratively across functions, levels, and departments toward shared objectives
High level of comfort with ambiguous situations and ability to maintain flexibility and adaptability while focusing on goals and important deadlines
Interest in and commitment to the mission of improving clinical access to high-quality cancer care for marginalized patient populations
Education: Advanced degree in a related field (e.g., healthcare administration, public health, business) or commensurate experience required
Experience (Type & Length): Minimum of 3 years of experience in Risk Management and Patient Safety within a healthcare setting
Certification/Licensure: Nursing or Physician Licensure preferred
Other: Office 365, ability to navigate electronic medical records, online regulatory portals and software applications
Preferred
Additional Infection Control experience preferred
Company
Signature Healthcare, MA
Located just 21 miles South of Boston, Signature Healthcare is Southeastern Massachusetts’ largest integrated healthcare system, including Brockton Hospital and Signature Medical Group, one of the largest multi-specialty, multi-site physician group practices on the South Shore.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Robert Haffey, MBA, MSN
President and CEO
Jason Radzevich
Chief financial officer & SVP
Company data provided by crunchbase