We are seeking an experienced healthcare quality and governance professional to support systemwide regulatory compliance, medical staff oversight, and professional practice evaluation initiatives. In this role, you will work closely with senior clinical leaders and cross-functional teams to strengthen quality standards and ensure alignment with national accreditation requirements. You will oversee critical credentialing and professional practice databases, ensuring data integrity, security, and effective reporting across multiple healthcare facilities. The position combines project management, regulatory expertise, database administration, and organizational policy development. You will also contribute to standardizing quality indicators, improving operational processes, and supporting continuous improvement initiatives. This is an opportunity to make a meaningful impact on healthcare governance and the quality and safety of specialized pediatric care within a collaborative, mission-driven environment.
Regulatory compliance and accreditation: Coordinate the planning, development, and implementation of regulatory standards and process improvements related to licensed independent practitioners, ensuring alignment with Joint Commission (JC), Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and applicable state and federal requirements.
Medical staff governance: Provide guidance and oversight to Medical Staff Offices to ensure that Medical Staff Bylaws, standard privileges, hospital regulations, procedural rules, and supporting documentation remain accurate and compliant with organizational policies and accreditation standards.
Policy development and maintenance: Develop, review, and recommend updates to systemwide policies, procedures, Medical Staff Bylaws, and Hospital Regulations and Procedural Rules to support consistent organizational practices and ongoing regulatory compliance.
Professional practice evaluation: Collaborate with healthcare quality leaders and medical group stakeholders to standardize quality indicators across specialties and oversee the implementation and monitoring of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) requirements.
Database administration and optimization: Serve as the system administrator and subject matter expert for MD-Stat and related statistical applications, ensuring database integrity, security, functionality, accurate data collection, and effective reporting.
Auditing and performance monitoring: Conduct regular database audits, monitor completion of quality metrics, identify compliance gaps, and coordinate corrective actions with Medical Staff Coordinators and Performance Improvement Directors.
Training and stakeholder support: Develop educational materials and deliver guidance on database applications, professional practice evaluation processes, credentialing requirements, and governance procedures to relevant teams.
Cross-functional project management: Lead and support special projects in collaboration with the Chief Medical Officer, Chief Quality Officer, Healthcare Quality and Safety leadership, Legal, Compliance, and Medical Group stakeholders.
International medical staff oversight: Provide guidance to medical staff coordination teams in Canada and Mexico on credentialing, privileging, regulatory compliance, and data integrity.
Governance and committee coordination: Lead collaborative initiatives and support steering committees focused on improving OPPE/FPPE processes, standardizing specialty-specific metrics, and evaluating performance thresholds.
Operational improvement: Research complex issues, analyze performance data, identify improvement opportunities, and implement solutions that strengthen governance, efficiency, and quality outcomes.
Enterprise collaboration: Maintain relevant professional services collaboration platforms and documentation repositories, ensuring effective information sharing and consistent communication across the organization.