Quality & Compliance Manager

Site: The Spaulding Rehabilitation Hospital Corporation

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

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

RN preferred

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)

• Leads in the analysis of adverse events and serious patient concerns related to clinical care and/or unexpected clinical outcomes, and adverse events and in follow-up visits of regulatory or accreditation agencies.

• Collaborates with local and MGB leadership to identify and mitigate risks to patients and the organization

• Manages a timely investigation and response to all patient concerns/complaints/grievances for clinical service areas including interviewing staff and reviewing medical records. Facilitates effective communication between patients, families, and providers to enhance patient/family-centered care and ensure common goals.

Physical Requirements

• Standing 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)

Pay Range

$79,560.00 - $115,720.80/Annual

Grade

7

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

1460 Spaulding Hospital-Cambridge, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

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.