Clinical Compliance Staff Specialist

Wentworth-Douglass Hospital, an affiliate of Mass General Brigham, is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.Job Summary:

This role will maintain sound organizational relationships and work well within a matrixed health care organization. This role will support the execution of long and short-term goals for the MGB clinical compliance programs.

Because this is a position in an active change management environment, this team member will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time.

Essential Duties:

• See everyone as worthy of respect and attention.

• Design care and services for and with each patient.

• Recognize that patients see quality service as quality care.

• Make it a priority to assist patients, visitors and colleagues.

• Take advantage of learning and growth opportunities.

• Understand organizational goals and priorities.

Responsibilities:

Support the MGB clinical compliance strategy within Wentworth Douglass Hospital, adhering to MGB standardized processes in regulatory oversight, quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within Wentworth Douglass Hospital.

• This role is an implementer of the clinical compliance programs at Wentworth Douglass Hospital.

• Executes compliance activities at Wentworth Douglass Hospital, ensuring adherence to MGB standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance.

• Continually and systematically plan, measure, and analyze accreditation compliance.

• Informs appropriate organization staff on regulatory program updates using applicable communication methods.

• Support clinical compliance as a member of various WDH and MGB committees.

• Development coordination and implementation of the regulatory continuous readiness plan

• Support and coordinate the regulatory application(s)

• Be the local Wentworth Douglass Hospital staff member for all compliance activities and support the Senior Manager in ensuring the hospital either meets or exceeds all measures.

• At the direction of the Senior Manager for Quality and Clinical Compliance will submit all required documentation and reports to all relevant accrediting and regulatory bodies for Wentworth Douglass Hospital

• Prepares reports and presentations as needed.

• 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 which are at risk.

• Provides strong bi-directional communication between the system and the site.

• Must be available to work in case of a hospital declared emergency.

• Must be available to assist during regulatory agency reviews.

• Performs other duties as assigned. 

Job Qualifications:

• Preferred: Knowledge of principles of quality measurement, governmental and regulatory quality requirements, process improvement. Demonstrated knowledge in executing improvements in clinical care, as well as holding themselves accountable to sustaining improvement over time. Ability to explain these domains to others, who may or may not have expertise within rigorous quality improvement.

• Demonstrated ability to execute a local quality performance and improvement portfolio.

• Support local site visits from TJC, CMS, DPH, DMH and other bodies as needed.

• Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements; problem assessment and problem-solving techniques; healthcare law; health care services.

• Excellent and effective communication skills, both verbal and written

• 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 energy and able to embrace challenges and change.

• Must be a team player and work well with a variety of people in all levels of the organization.

• Uphold Behavioral Standards in day-to-day interactions.

Experience:

• Required: Experience in quality and/or clinical compliance within a hospital.

• Preferred: Minimum of 5 years' experience in quality and/or clinical compliance within a hospital.

Education/Degree requirements:

• Required: Bachelor's degree

• Preferred: Clinical background

Licensure, Certifications, or Registration:

• Preferred: Registered Nurse