Quality & Regulatory Manager

Provides oversight and supervision to the Quality and Regulatory Department, including its operations and staff. This position identifies site performance improvement activities and provides support through leadership and the Quality Management System. This position is responsible for the site’s document management program. The Manager collaborates with hospital and medical leadership and team members to develop their understanding and accountability for regulatory compliance, including management of the hospital’s regulatory readiness program, internal and external audit program, and through corrective action planning. This position support peer review and quality review activities.

Major Responsibilities:

• Manages the hospitals’ quality and performance improvement program and processes, facilitating data analysis and improvement in organizational quality, efficiency, safety, and engagement.
• Manages the regulatory program including assuring compliance with national, state, and local external agency requirements, providing oversight to the internal and external audit program and the corrective action planning program for compliance.
• Manges team member, leader, and medical staff leadership compliance with regulatory and external agency requirements, including providing education, training, and resources where needed.
• Provides information, data, and reports for the hospital’s peer review program, including support of the OPPE and FPPE program.
• Manages and supervises the team members in the Quality and Regulatory department, including day to day activities.
• Prioritizes site clinical and non-clinical improvement opportunities including oversight of performance improvement activity.
• Support the Quality Management Oversight Committee and its related processes.
• Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
• Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.

Licensure, Registration and/or Certification Required:

None Required.

Education Required:

Bachelor’s Degree in healthcare or related field. 

Experience Required:

Typically requires 5 years of experience in quality in acute care setting.   

Knowledge, Skills & Abilities Required:

• Clinical knowledge about hospital care related processes
• Competency in performance improvement methodologies and tools
• Competency in change management
• Ability to urgently respond to regulatory requests and patient safety events
• Organizational and presentation skills
• Proficient in MS Office
• Proficient in data analytics

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.