Manger, Transplant Quality & Regulatory Compliance

Job description

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. In this role, the Manager, Transplant QAPI & Regulatory Compliance provides leadership for transplant quality assessment, performance improvement, patient safety, and regulatory compliance across hospital solid organ transplant programs. Reporting to the Director of the Transplant Institute, this role oversees the design and execution of a comprehensive, data-driven QAPI program to ensure sustained compliance with CMS Conditions of Participation, OPTN requirements, and other applicable regulatory standards. This position serves as the hospital’s subject-matter expert in transplant quality and regulatory affairs. Job Description: ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to): Leads the development, implementation, and oversight of the integrated Quality Assessment and Performance Improvement (QAPI) program across hospital solid organ transplant programs. Ensures continuous compliance with CMS Conditions of Participation, OPTN policies, HRSA requirements, and applicable state regulations. Maintains ongoing survey readiness and leads preparation for CMS certification, re-certification, and focused or unannounced regulatory surveys. Oversees investigation, documentation, and resolution of transplant-related adverse events, near misses, and patient safety concerns. Analyzes transplant outcomes and operational performance data to identify trends, risks, and improvement opportunities. Develops, monitors, and sustains corrective action plans to address quality or regulatory findings. Ensures accuracy, integrity, and timeliness of transplant quality data, regulatory submissions, and internal and external reporting. Prepares and presents quality, safety, and regulatory reports to transplant leadership and governance committees. Serves as a strategic advisor to transplant clinical and administrative leadership on quality, safety, and regulatory risk. Supports onboarding, certification, and quality infrastructure development for new or expanding hospital transplant programs and services. QUALIFICATIONS: Bachelor’s degree required; Master’s degree in healthcare administration, healthcare informatics, public health, or related field preferred. Minimum of 5 years of progressive experience in transplant quality, regulatory compliance, or performance improvement within an academic medical center or transplant program. Demonstrated expertise in CMS Conditions of Participation and OPTN regulatory requirements. Professional certification in quality (CPHQ), patient safety, or healthcare compliance preferred. OTHER REQUIREMENTS: Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values. Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment This position requires the ability to perform work in a typical office and clinical environment, including sitting or standing for extended periods and using a computer and standard office equipment. Proficiency in written and verbal English communication. Pay Range: $120,000.00 USD - $150,000.00 USD The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. 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) as a condition of employment. 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