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Exemption Status:
Exempt

Hiring Range:
$111,384.00 - $200,491.20
Please note that the final offer may vary within this range based on a candidate's experience, skills, qualifications, and internal equity considerations.

Schedule Details:
Monday through Friday

Scheduled Hours:
8-5

Shift:
1 - Day Shift, 8 Hours (United States of America)

Hours:
40

Cost Center:
99940 - 6613 System Quality Informatics

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Reporting directly to the SVP, Chief Quality Officer / Chief Clinical Informatics Officer, the System Quality & Regulatory Programs Director provides enterprise-level leadership and strategic oversight for quality, safety, and health equity regulatory programs across the UMMH system. This role serves as the system's authoritative expert on external quality programs and leads the organization's strategy, analysis, and data submission efforts to ensure compliance, transparency, and optimal performance.
The Director drives systemwide quality measurement strategy and partners with executive, clinical, and operational leaders to advance UMMH's goals for quality and patient safety. This role builds and sustains strong collaborative relationships across all levels of the organization, working closely with clinical and administrative leadership, as well as quality managers and analysts at both the entity and system levels.
As a key member of the System Quality and Clinical Informatics leadership teams, the Director provides thought leadership, operational guidance, and subject matter expertise across all UMMH entities. The position plays a critical role in shaping systemwide quality and regulatory strategy, ensuring alignment, integration, and excellence in performance across the enterprise.

I. Major Responsibilities:
1. Serves as the UMMH system's subject matter expert on programs around quality, value-based purchasing, and all other major external quality, safety, patient experience, and health equity reporting for the acute care setting.
2. Provides executive-level leadership on emerging programs. Includes analysis of proposed rules and identifying the impacts on the system, both operationally and financially. Leads system preparedness for new quality reporting programs.
3. Directs UMMH's enterprise-wide submission of data to key external and regulatory agencies around quality, e.g. Vizient, Medisolv, CMS (Promoting Interoperability, IQR, OQR, IPFQR), TJC, MassHealth, etc.
4. Ensures the highest standards of data integrity for all internal and external quality reporting, maintaining compliance with organizational policies and regulatory expectations.
5. Leads system-based quality improvement and regulatory compliance initiatives.
6. Participates in and supports entity specific efforts at quality improvement. Ensures this improvement efforts align with external quality standards and integrate between hospital quality departments.
7. Develops and executes on methods for capturing quality data, whether through Epic, electronic systems or manual abstraction.
8. Facilitates and assures successful execution of projects in area of their domain, as assigned.
9. Designs and evaluates collection of data for clinical purposes, including tracking and interpretation of individual patient outcomes needed to provide personalized and more predictive health care.
10. Provides leadership in EMR planning, policy development, strategies around analytics and reporting. Participate in training, activation and optimization activities in this area.
11. Communicates broadly with staff (hospital, office, and community-based) and UMMH Leadership as needed to ensure that there is alignment among the UMMHC stakeholders.
12. Supports strategies to maximum reimbursement for pay for performance programs.
13. Ensures organizational compliance with regulatory agencies such as Joint Commission, DPH, etc. Develop and maintains procedures necessary to meet regulatory requirements.
14. Applies Lean methodology, developing and monitoring ongoing measures of success.

II. Standard Management Level Responsibilities:
1. Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
2. Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.
3. Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.
4. Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with system-wide initiatives.
5. Encourages and supports diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients and visitors.
6. Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.
7. Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
8. Ensures compliance with regulatory agencies such as Joint Commission, DPH, etc. Develops and maintains procedures necessary to meet regulatory requirements.
9. Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.
10. Ensures adequate equipment and supplies for department.
11. Develops and maintains established departmental policies, procedures, and objectives.
12. Ensures compliance to all health and safety regulations and requirements.
13. Maintains, regular, reliable, and predictable attendance.
14. Performs similar or related duties as required or directed.
All responsibilities are essential job functions.

III. Position Qualifications:
License/Certifications/Education:
Required:
1. Master's or other professional degree in related field.
2. 7 years of related work experience.
Preferred:

Experience/Skills:
Required:
1. Understanding and use of Lean/Six Sigma methodology.
2. Must possess a strong knowledge of clinical processes and operations in a large health care system, allowing candidate to perform effectively in a complex changing environment.
3. Knowledge of project management philosophy with the ability to coordinate, plan and execute projects with wide-ranging and complicated interrelationships. Able to deliver projects on time and within budget.
4. Ability to work collaboratively, influencing decisions and outcomes, facilitating consensus.
5. Highly skilled at needs assessment, facilitation of project implementation, and organizational change or development.
6. Excellent verbal, presentation, written and interpersonal communication skills. Ability to analyze complex problems and develop recommendations and solutions. Excellent leadership, quality improvement, and management skills.
7. Ability to educate and mentor. Capable of relating to diverse age and demographic backgrounds.
Preferred:
1. Management experience.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.