Quality & Compliance Manager
Apply NowCompany: Mass General Brigham
Location: Cambridge, MA 02139
Description:
Site: The Spaulding Rehabilitation Hospital Corporation
At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission-from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare - people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds - to apply.
Job Summary
Summary
Responsible for overseeing and ensuring the quality and compliance of healthcare services within the organization. This position involves developing, implementing, and monitoring quality improvement programs, ensuring adherence to regulatory requirements, and leading initiatives to improve patient care, safety, and operational efficiency.
Does this position require Patient Care?
No
Essential Functions
-Execute quality and clinical compliance strategy within the organization, ensuring adherence to standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within.
-Track & execute necessary improvement for CMS conditions of participation, government, and private payer pay for performance activities in the quality and equity domains.
-Responsible for partnering with the data and analytics team as needed to ensure that reporting to CMS and other regulatory bodies is timely and correct.
-Execute and track any performance improvements as a result of safety events.
-Executes quality performance improvement plans and partners with local teams and department or floor-based teams to implement improvements as needed.
-Executes compliance activities, ensuring adherence to standardized processes around tracer activity, site-level preparedness activities, and measuring/monitoring compliance.
-Staff member for all compliance activities, ensuring the organization meets or exceeds all those measures.
-Supports local training and educational programs as needed.
-Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas that are at risk.
Qualifications
Education
Bachelor's Degree Related Field of Study required
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Experience
Experience in quality and clinical compliance within a hospital 3-5 years required and Clinical background experience 3-5 years preferred
Knowledge, Skills and Abilities
- Knowledge of principles of quality measurement, governmental and regulatory quality requirements, and process improvement.
- Demonstrated knowledge in executing improvements in clinical care, as well as holding themselves accountable to sustaining improvement over time.
- Demonstrated ability to execute a local quality performance and improvement portfolio.
- Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements, problem assessment and problem-solving techniques, health care law, health care services
- Excellent and effective verbal and written communication skills, as well as organization.
- Ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills
- Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic and able to embrace challenges and change.
Additional Job Details (if applicable)
Physical RequirementsStanding Occasionally (3-33%) Walking Occasionally (3-33%) Sitting Constantly (67-100%) Lifting Occasionally (3-33%) Carrying Occasionally (3-33%) Pushing Rarely (Less than 2%) Pulling Rarely (Less than 2%) Climbing Rarely (Less than 2%) Balancing Occasionally (3-33%) Stooping Occasionally (3-33%) Kneeling Rarely (Less than 2%) Crouching Rarely (Less than 2%) Crawling Rarely (Less than 2%) Reaching Occasionally (3-33%) Gross Manipulation (Handling) Constantly (67-100%) Fine Manipulation (Fingering) Frequently (34-66%) Feeling Constantly (67-100%) Foot Use Rarely (Less than 2%) Vision - Far Constantly (67-100%) Vision - Near Constantly (67-100%) Talking Constantly (67-100%) Hearing Constantly (67-100%)
Remote Type
Hybrid
Work Location
1575 Cambridge Street
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
The Spaulding Rehabilitation Hospital Corporation is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission-from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare - people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds - to apply.
Job Summary
Summary
Responsible for overseeing and ensuring the quality and compliance of healthcare services within the organization. This position involves developing, implementing, and monitoring quality improvement programs, ensuring adherence to regulatory requirements, and leading initiatives to improve patient care, safety, and operational efficiency.
Does this position require Patient Care?
No
Essential Functions
-Execute quality and clinical compliance strategy within the organization, ensuring adherence to standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within.
-Track & execute necessary improvement for CMS conditions of participation, government, and private payer pay for performance activities in the quality and equity domains.
-Responsible for partnering with the data and analytics team as needed to ensure that reporting to CMS and other regulatory bodies is timely and correct.
-Execute and track any performance improvements as a result of safety events.
-Executes quality performance improvement plans and partners with local teams and department or floor-based teams to implement improvements as needed.
-Executes compliance activities, ensuring adherence to standardized processes around tracer activity, site-level preparedness activities, and measuring/monitoring compliance.
-Staff member for all compliance activities, ensuring the organization meets or exceeds all those measures.
-Supports local training and educational programs as needed.
-Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas that are at risk.
Qualifications
Education
Bachelor's Degree Related Field of Study required
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Experience
Experience in quality and clinical compliance within a hospital 3-5 years required and Clinical background experience 3-5 years preferred
Knowledge, Skills and Abilities
- Knowledge of principles of quality measurement, governmental and regulatory quality requirements, and process improvement.
- Demonstrated knowledge in executing improvements in clinical care, as well as holding themselves accountable to sustaining improvement over time.
- Demonstrated ability to execute a local quality performance and improvement portfolio.
- Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements, problem assessment and problem-solving techniques, health care law, health care services
- Excellent and effective verbal and written communication skills, as well as organization.
- Ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills
- Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic and able to embrace challenges and change.
Additional Job Details (if applicable)
Physical Requirements
Remote Type
Hybrid
Work Location
1575 Cambridge Street
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
The Spaulding Rehabilitation Hospital Corporation is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.