System Quality & Regulatory Programs Manager

Position Overview 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. Major Responsibilities Serve 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. Provide executive‑level leadership on emerging programs, including analysis of proposed rules and identifying their operational and financial impacts, and lead system preparedness for new quality reporting programs. Direct 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. Ensure the highest standards of data integrity for all internal and external quality reporting, maintaining compliance with organizational policies and regulatory expectations. Lead system‑based quality improvement and regulatory compliance initiatives. Participate in and support entity‑specific efforts at quality improvement, ensuring these efforts align with external quality standards and integrate across hospital quality departments. Develop and execute methods for capturing quality data, whether through Epic, electronic systems or manual abstraction. Facilitate and assure successful execution of projects in the director’s domain, as assigned. Design and evaluate the collection of data for clinical purposes, including tracking and interpreting individual patient outcomes needed to provide personalized and more predictive health care. Provide leadership in EMR planning, policy development, strategies around analytics and reporting; participate in training, activation and optimization activities in this area. Communicate broadly with staff (hospital, office, and community‑based) and UMMH Leadership to ensure alignment among stakeholders. Support strategies to maximize reimbursement for pay‑for‑performance programs. Ensure organizational compliance with regulatory agencies such as Joint Commission, DPH, etc., developing and maintaining necessary procedures. Apply Lean methodology, developing and monitoring ongoing measures of success. Management Level Responsibilities Direct and supervise assigned personnel, including performance evaluations, scheduling, orientation, and training, and make recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolve grievances and other personnel problems within position responsibilities. Develop and recommend budgets for the areas managed, and manage activities to assure financial goals are met. Coordinate the assignment of tasks and help resolve technical and operational problems; evaluate impact of solutions to ensure goals are achieved. Provide effective direction, guidance, and leadership over staff for effective teamwork and motivation, fostering integration with system‑wide initiatives. Encourage and support diverse views and approaches, demonstrate Standards of Respect, and contribute to a professional, respectful, tolerant, civil, and accepting environment for all employees, patients, and visitors. Integrate diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc. Participate in performance improvement initiatives and demonstrate use of quality improvement in daily operations. Ensure compliance with regulatory agencies such as Joint Commission, DPH, etc., developing and maintaining necessary procedures. Ensure that the department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures. Ensure adequate equipment and supplies for the department. Develop and maintain established departmental policies, procedures, and objectives. Ensure compliance with all health and safety regulations and requirements. Maintain regular, reliable, and predictable attendance. Perform similar or related duties as required or directed. Position Qualifications License/Certifications/Education Master’s or other professional degree in a related field. 7 years of related work experience. Experience and Skills Understanding and use of Lean/Six Sigma methodology. Strong knowledge of clinical processes and operations in a large health‑care system. Knowledge of project management philosophy with the ability to coordinate, plan, and execute projects with wide‑ranging and complicated interrelationships, delivering on time and within budget. Ability to work collaboratively, influence decisions and outcomes, and facilitate consensus. Highly skilled at needs assessment, facilitation of project implementation, and organizational change or development. 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. Ability to educate and mentor; capable of relating to diverse age and demographic backgrounds. Preferred Management experience. Unless a certification, licensure, or registration is required, an equivalent combination of education and experience which provides proficiency in the relevant areas 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. 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. 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