MelroseWakefield Hospital · 7 hours ago
Regulatory Readiness Program Manager
MelroseWakefield Hospital
Full-time
Onsite
Mid, Senior Level
$84K/yr - $107K/yr
3+ years expMelroseWakefield Hospital is focused on enhancing patient quality care standards. The Regulatory Readiness Program Manager will develop and implement programs to ensure compliance with clinical quality and patient safety standards, while also leading continuous improvement efforts across the organization.
Health CareHome Health CareMedical Device
Responsibilities
Serves as the organizational expert for The Joint Commission, DPH and CMS standards, regulations, and Conditions of Participation (CoPs)
Responsible for the interpretation and communication of regulatory requirements throughout the organization
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
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
Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance
Builds effective, supportive, and productive relationships with leadership, staff and faculty
Facilitates development of tools, policies, procedures, and learning aids to promote compliance with standards
Provides timely communication regarding new and revised standards and interpretations to administrative and clinical leadership, staff and faculty
Works closely and builds effective working relationships with accreditation and regulatory agencies
Responsible for all aspects of the plan to ensure continuous readiness with clinical regulatory and accreditation requirements
Responsible for communication of the continuous readiness plan to leadership and key groups
Works closely with Patient Safety/Risk Management, Quality Improvement and Data Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance
Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS
Works with Patient Safety/Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events
Stays current with new standards
Develops, coordinates, and implements all aspects of the annual continuous readiness plan
Performs ongoing assessment of the readiness plan
Identifies needed improvements
Prepares and implements action plans to achieve needed improvement and compliance
Provides ongoing communication with regulatory agencies regarding survey and readiness activities
Completes annual TJC application
Supports response to agency requests for revision and corrective action plans
Qualification
Required
Bachelor's degree
Three (3) years of experience in healthcare leadership, Regulatory, Quality, and Patient Safety
Preferred
Master's degree
Certified Professional in Healthcare Quality (CPHQ)
Five (5) years of experience in healthcare leadership, Regulatory, Quality and Patient Safety
Benefits
Comprehensive Total Rewards package that supports your health, financial security, and career growth
Company
MelroseWakefield Hospital
MelroseWakefield Hospital and Lawrence Memorial Hospital provide high-quality, community-based care.
1001-5000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase