Staff Specialist, Quality & Compliance

This role is the local team member who performs the daily activities of clinical compliance, quality performance and improvement at MEEI Hospital. This role will report directly to the Quality Director and the AMC Clinical Compliance Director and is responsible for the execution of the quality and clinical compliance programs.

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 quality and 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 Job Duties and Responsibilities:

General:

• Support the MGB quality and clinical compliance strategy within MEEI, adhering to MGB standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising.
• This role is an implementer of the quality and clinical compliance programs at MEEI

Quality:

• Serve as the local team member at MEEI tracking and executing necessary improvement for CMS conditions pf participation, government and private payer pay for performance activities in the quality and equity domains.
• Responsible for partnering with the MGB data and analytics team as needed to ensure that reporting to CMS and other regulatory bodies (DMH/CMS requirements), private payer contracting, external benchmarking bodies, PSIs, HACs, and coordination requires:
  
  
  
  • Execute and track any performance improvements as a result of safety events.
  • Support site infection control team to monitor and improve performance and respond to data to lower the risk of infections to our patients.
  • Support the MEEI ACMO as needed to execute system goals and site level improvements.
  
  
  
  
• Executes quality performance improvement plans, and partners with local teams/departments or floor-based teams to implement improvements as needed.
• Executes and tracks performance of process changes or performance improvement activities.
• Performs QAPI documentation

Clinical Compliance:

• Executes compliance activities, ensuring adherence to MGB standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance.
• Be the local MEEI staff member for all compliance activities and supports the AMC Clinical Compliance Director in ensuring MEEI meets or exceeds those measures.
• Responsible for submitting all required documentation and reports to all relevant accrediting and regulatory bodies for MEEI (DPH, DMH, TJC, BORIM, MedSUN).

Other:

• 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.
• Performs other duties as assigned.

Essential Knowledge, Skills, and Experience Required for the Position:

• Undergraduate degree required.
• Clinical background preferred.
• Minimum 2-years' experience in quality and clinical compliance within a hospital setting.
• Knowledge of principles of quality measurement, governmental and regulatory quality requirements, process improvement.
• Supports local site visits from regulatory bodies as needed.
• Excellent and effective communication skills.
• Ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills.
• Excellent organizational skills
• Uphold behavioral standards in day-to-day interactions.

Specialty Requirements:

• Must be available to work in the case of a hospital declared emergency.
• Must be available to assist during regulatory agency reviews.

Massachusetts Eye and Ear is proud to be an equal-opportunity employer and is committed to providing a workplace free from harassment or discrimination. All employment decisions are made without regard to race, color, age, gender, gender identification, sexual orientation, religion, marital status, sex, pregnancy or conditions related to pregnancy, national origin/ancestry, citizenship, disability, military status, genetic information, or any other basis prohibited by law. These protections extend to all management practices and decisions, including recruitment and hiring practices, appraisal systems, promotions, training, and career development programs.