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Beth Israel Lahey Health Program Manager - Regulatory and Accreditation Programs in Boston, Massachusetts

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Under the direction of the Director of Regulatory Affairs, the Performance Assessment and Regulatory Compliance (PARC) team of Beth Israel Deaconess Medical Center's Silverman Institute for Health Care Quality and Safety provides leadership for the overall assessment of performance and regulatory compliance at BIDMC, and works in collaboration with teams from across the Beth Israel Lahey Health (BILH) System.

This position can work remotely however as any unannounced or anticipated triennial Survey approaches (and in the months following it), this person will join the PARC team onsite for the facilitation of a successful survey. There is a dedicated touch-down space in Boston, MA where the team gathers regularly.

Job Description:

The Regulatory and Accreditation Program Manager reports to the Director, Regulatory Affairs. Manages the accreditation/regulatory program requirements related to Joint Commission, CMS and the MA Department of Public Health/Licensing requirements.

This position Is responsible for administrative and coordinating functions Pre and Post accreditation surveys (Application, communicates with service line leads regarding action plan and next step in preparation for or following inspection surveys, coordinates response assessment dashboards, and MOS Design, etc.) as well as other large scale quality and safety survey coordination and compliance.

Acts as project resource and partner with the project managers, data abstractors, data analyst and other hospital staff to create and customize tools and media regarding accreditation requirements to identified members of the BIDMC community and clinical affiliates. This position supports the BIDMC Transparency agenda through regular updates and maintenance of the internal portal content and external website related to quality and safety.

Essential Responsibilities:

  • Acts as staff member to hospital wide accreditation readiness committee(s) and working subgroup contributor. Performs follow-up activities/project management support. Coordinates the dissemination of performance assessment and regulatory updates to appropriate medical center staff.

  • Ensures that the accreditation readiness program is in place by coordinating 'mock surveys' and collecting required supporting documentation, data and action plans. Participates in the development of educational resources for the general staff regarding standard/regulatory updates.

  • Screens and routes telephone calls as related to patient satisfaction/service excellence survey, performance assessment and/or Joint Commission standards.

  • Coordinates the development of newsletters and other communication methods for the Office, including format, content development, and graphics. Maintains liaison relationship with peers at BID System hospitals and clinical affiliates of BIDMC by coordinating periodic (quarterly) joint sessions/meetings of key accreditation and quality and safety leaders; disseminates pertinent related materials.

  • Conducts observation audit and chart review to support prioritized opportunities for improvement of projects related to annual operating plan and/or regulatory related topics using PDSA process. Contributes to the assessment of baseline performance and ensures improvement/corrective action plan durability. Manages data collection and recommends improvement to the process and improves workflow.

Required Qualifications:

  • Bachelor's degree required. Master's degree preferred.

  • 3-5 years related work experience required.

  • Experience with accreditation and licensing survey preparation activity in a health care setting.

  • Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.

Preferred Qualifications:

  • Bachelor's degree in clinical/healthcare management or related field preferred.


  • Decision Making: Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

  • Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.

  • Independence of Action: Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.

  • Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

  • Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

  • Knowledge: Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.

  • Team Work: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.

  • Customer Service: Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Physical Nature of the Job:

Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more ( about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled