At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, 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 a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Job Summary
Summary:Acts in an advisory role supporting the hospital's programs that address accreditation and related regulatory requirements, such as the Joint Commission, DPH, and CMS.
Responsible for supporting QAPI programs and managing special clinical projects to ensure regulatory compliance. May also assist with related risk management or patient safety activities.
Does this position require Patient Care? No
Essential Functions:
-Conducts compliance audits and reviews to assess adherence to regulatory and accreditation standards within clinical settings.
-Advises clinical departments on regulatory requirements and best practices, assisting in the development of compliance policies and procedures.
-Identifies areas of non-compliance, investigates root causes, and develops action plans to address deficiencies.
-Prepares and maintains detailed reports on compliance activities, presenting findings to leadership as needed.
-Educates staff on clinical compliance, regulatory changes, and accreditation standards through training and development sessions.
-Monitors updates to federal and state regulations, ensuring clinical practices align with current requirements.
-Supports accreditation and certification processes, including preparation for audits and surveys.
Qualifications
Education
Bachelor's Degree Related Field of Study required and Master's Degree Related Field of Study preferred
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Experience
Clinical experience 5-7 years required and Project management in a complex organization 5-7 years required
Knowledge, Skills and Abilities
- Strong knowledge of regulatory and accreditation standards in healthcare (e.g., CMS, Joint Commission).
- Excellent problem-solving skills with the ability to develop effective compliance strategies.
- Detail-oriented with strong analytical skills to assess compliance risks and track corrective actions.
- Effective communicator, able to convey complex regulatory requirements clearly to staff at all levels.
- Proficiency in compliance and quality management software and reporting tools.
Additional Job Details (if applicable)
Remote Type
Hybrid
Work Location
41-45 Avenue Louis Pasteur
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
The Brigham and Women's Hospital, Inc. is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.