Manager, Accreditation & Regulatory Compliance

Location: 1035 Cambridge Street 

Work Days: M-F with some flexibility required  

Category: Professional and Management  

Department: Risk Management  

Job Type: Full time  

Work Shift: Day 

Hours/Week: 40

Union Name: Non Union

The Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate preventable harm for all patients and staff, provide high value, equitable, evidence-based care, create an excellent care experience and to develop institutional capacity in improvement science and promote data driven decision making. Join our talented team to contribute towards the mission of our organization.

Under the direction of the Senior Director of Risk Management & Patient Safety, and working collaboratively with Quality and Safety leadership, the Manager, Accreditation & Regulatory Compliance leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health and Center for Medicare and Medicaid Services. In this role the Manager, Accreditation & Regulatory Compliance proactively plans, implements, coordinates and continually improves the Cambridge Health Alliance’s (CHA) efforts related to compliance, accreditation, and licensure requirements.

Key Job Responsibilities: 

• Responsible for the overarching development and maintenance of a continuous readiness program across the institution for all accreditation and regulatory oversight bodies.

• Serves as the organizational expert for The Joint Commission, DMH, DPH and CMS standards, regulations and conditions of participation.

• Responsible for the interpretation and communication of regulatory and licensing requirements throughout the organization.

• Acquires and demonstrates expertise in specialized accreditation programs such as the Commission on Cancer (CoC), Bureau of Substance Abuse Services (BSAS), Commission for the Accreditation of Birth Centers, TJC and MassHealth Health Equity standards, NCQA Certification, Utilization Review Accreditation Commission (URAC), among others. 

• Provides education and consultation to administrative, operational, and clinical leadership, staff and faculty throughout CHA regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

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

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

• Provides timely communication regarding new and revised TJC, DMH, DPH, and CMS standards and interpretations to administrative and clinical leadership and staff.

• Works closely and builds effective working relationships with accreditation and regulatory agencies, i.e.The Joint Commission, DMH, DPH and CMS.

• Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DMH, DPH and CMS. Serves as a member of the Patient Safety Committee and other committees as deemed appropriate.

Qualifications: 

• Baccalaureate Degree, BSN highly preferred. Master's Degree with a healthcare focus is also highly preferred.

• 3-5 years of experience with The Joint Commission, DPH and other regulatory requirements and survey processes.

• Strong working knowledge of all applicable TJC, CMS, DPH and DMH standards to support the organization’s continual regulatory readiness. 

• Outstanding team player with the ability to self-initiate and independently start and complete projects without direction .

• Ability to develop effective relationships with a broad array of people from diverse backgrounds.

• Strong interpersonal skills; ability to establish supportive, collegial relationships.

• Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.

• Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.

• Demonstrated skill in change management and quality improvement.

• Knowledge of clinical terminology.

• Ability to learn and effectively use computer software, such as electronic health records and data entry.

 
In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.