Site: The Brigham and Women's Hospital, Inc.
Job Summary
Summary:
-Acts in an advisory role supporting the hospital's programs that address accreditation and related regulatory requirements, such as the Joint Commission, DPH, and CMS. Responsible for supporting QAPI programs and managing special clinical projects to ensure regulatory compliance. May also assist with related risk management or patient safety activities.
Does this position require Patient Care? No
Essential Functions:
-Conducts compliance audits and reviews to assess adherence to regulatory and accreditation standards within clinical settings.
-Advises clinical departments on regulatory requirements and best practices, assisting in the development of compliance policies and procedures.
-Identifies areas of non-compliance, investigates root causes, and develops action plans to address deficiencies.
-Prepares and maintains detailed reports on compliance activities, presenting findings to leadership as needed.
-Educates staff on clinical compliance, regulatory changes, and accreditation standards through training and development sessions.
-Monitors updates to federal and state regulations, ensuring clinical practices align with current requirements.
-Supports accreditation and certification processes, including preparation for audits and surveys.
Qualifications
Education
Bachelor's Degree required and Master's Degree Related Field of Study preferred
Can this role accept experience in lieu of a degree?
No
Experience:
Clinical experience 5-7 years required
Project management in a complex organization 5-7 years required
Knowledge, Skills and Abilities
- Strong knowledge of regulatory and accreditation standards in healthcare (e.g., CMS, Joint Commission).
- Excellent problem-solving skills with the ability to develop effective compliance strategies.
- Detail-oriented with strong analytical skills to assess compliance risks and track corrective actions.
- Effective communicator, able to convey complex regulatory requirements clearly to staff at all levels.
- Proficiency in compliance and quality management software and reporting tools.
Additional Job Details (if applicable)
Remote Type
Hybrid
Work Location
1620 Tremont 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.
Mass General Brigham Competency FrameworkAt 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.
