System Quality & Regulatory Programs Manager

ummh; Worcester (MA); On-site; USD 111,000 - 200,000; Full time

Benefits offered by this job

Signing bonus

Job summary

UMass Memorial Health is seeking a System Quality & Regulatory Programs Manager to provide enterprise‑level leadership for quality, safety and health equity regulatory programs across the health system. The role drives strategy, analysis, and data submission to ensure compliance, transparency, and optimal performance.

Reporting to the SVP, Chief Quality Officer, you will collaborate with executive, clinical, and operational leaders to advance quality and patient safety, build cross‑entity

Qualifications

• Provides enterprise‑level leadership on quality, safety, and health equity regulatory programs.
• Leads strategy, analysis, and data submission for compliance and transparency.
• Collaborates with clinical, operational and leadership to advance quality and patient safety.

Responsibilities

• Serves as the system's SME on external quality, safety, patient experience, and health equity reporting for acute care.
• Provides executive‑level leadership on emerging programs and analyzes impact on the system.
• Directs enterprise‑wide data submission to external/regulatory agencies (CMS, Vizient, TJC, MassHealth).
• Ensures data integrity and regulatory compliance across reporting.
• Leads system‑wide quality improvement and regulatory compliance initiatives.
• Supports entity‑level quality improvement efforts and aligns with external standards.
• Develops methods for capturing quality data (Epic, electronic systems, manual abstraction).
• Facilitates successful execution of projects; designs data collection for clinical outcomes.
• Leads EMR planning, analytics, and reporting strategies; participates in training and activation.

Job description

Exemption Status: Exempt

Hiring Range: $111,384.00 - $200,491.20 (based on a full time schedule of 40 hours per week).

Please note that the final offer will vary based on scheduled hours. Compensation for part-time or reduced schedules will be prorated based on scheduled weekly hours, 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 Qualificat