System Quality & Regulatory Programs Manager

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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.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Reporting directly to the SVP, Chief Quality Officer / Chief Clinical Informatics Officer, the System Quality & Regulatory Programs Manager 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.
This role 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 manager 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.

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.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at [email protected]. We will make every effort to respond to your request for disability assistance as soon as possible.