Program Manager, Clinical Regulatory Compliance

Job Details

Job ID:

10 Brookline Place West, Brookline, MA 02445


Employment Type:
Full time

Work Location:
Hybrid: 2-3 days onsite/week


The Program Manager, Clinical Regulatory Compliance & Accreditation works directly with staff, management, and senior leadership to coordinate and perform day-to-day activities related to regulatory compliance across all Dana-Farber sites.  This role also supports other quality, safety, and regulatory initiatives in the Quality and Patient Safety Department. The Program Manager, Clinical Regulatory Compliance & Accreditation will also play a critical role in leading Dana-Farber’s regulatory steering committee.

Under the supervision of the Senior Director for Quality Assurance and Regulatory Compliance, the Program Manager, Clinical Regulatory Compliance & Accreditation will support various initiatives in the areas of clinical regulatory compliance. Examples include data analysis and reports to meet the regulatory requirements of The Joint Commission (TJC), Department of Public Health (DPH), and the Centers for Medicare and Medicaid Services (CMS).  This role will collaborate with the leaders of committees and task forces at Dana-Farber, Brigham & Women’s Hospital, and Boston Children’s Hospital, to assure coordination and consistent documentation of regulatory action plans and follow-up activity.  As a key member of the Quality Assurance and Regulatory Compliance team, this role will support the regulatory needs of Dana-Farber’s new inpatient cancer hospital and new collaboration with Beth Israel Deaconess Medical Center as that work ramps up.

Located in Boston and the surrounding communities, Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

This position’s work location is hybrid with two or three days per week remote. The selected candidate may only work remote days from a New England state (ME, VT, NH, MA, CT, RI).  


  • Leads technical support for regulatory and accreditation compliance, including coordination of Joint Commission survey readiness (pre- and post-survey follow up), shepherding action plans associated with the submission of the Focused Standards Assessment tool, and conducting related educational programs and tracers in our clinical locations.
  • Supports the Senior Director in managing regulatory and accreditation compliance initiatives. Identifies major phases, implementation steps, key stakeholders, timelines, resource needs, and potential obstacles or issues for escalation.
  • In collaboration with the Senior Director, coordinates Dana-Farber’s regulatory steering committee – the Continuous Readiness Leadership (CRL) Committee.
  • Evaluates the impact of new regulatory requirements as they are released and prepares summaries, recommendations, and actions plans as relevant. Directs implementation of new regulatory requirements and surveys as they arise, actively supporting staff throughout the Institute.
  • Compiles Joint Commission readiness reports to keep senior leadership informed at all times. Presents data and analyses to key stakeholder groups independently, as requested.
  • Staffs and attends various ad-hoc and standing committees to ensure support, discussion, documentation, and general awareness of current, emerging, and other regulatory changes.
  • Implements and maintains a system to notify staff and leadership of current and upcoming regulatory changes from The Joint Commission and other agencies.
  • Prepares regulatory readiness summaries and recommendations for prioritization of decisions to Dana-Farber leadership.
  • Coordinates and leads formal education programs to a wide variety of stakeholders across Dana-Farber regarding compliance expectations, feedback on readiness efforts, strategies for success, and communication plans.
  • Manages development of tools, learning aids, standard reports, and monitoring plans to promote compliance with all regulatory standards. Conducts ongoing tracing activities and document reviews.
  • Acts as liaison to various departments within Dana-Farber – inclusive of our inpatient hospital and all ambulatory sites across our main and regional campuses – to ensure continuous regulatory readiness.
  • Maintains relevant project data and conducts related analyses, pulling results into meaningful reports and presentations as needed.
  • Performs routine audits of records and observes workflows to ensure compliance with policies.
  • In collaboration with inpatient hospital leadership, ensures timely review of all inpatient hospital policies.
  • Occasional travel required to regional campuses in the greater Boston area to evaluate regulatory readiness and provide educational opportunities to frontline staff.
  • Performs all other related duties as required.


  • Bachelor’s degree required; Master’s degree in healthcare administration/management, public health, or other relevant field of study preferred.
  • 3 years of experience in a healthcare organization required; preferably in a related position. 
  • Proficiency in IBM PC systems and applications including Excel, PowerPoint, and other database management software required. 
  • Data management and analytic system experience preferred. 


  • Knowledge of current issues in the healthcare environment preferred, particularly regarding quality measurement, regulatory compliance, and patient safety
  • Demonstrated project management skills and experience
  • Excellent organizational skills with a strong focus upon managing details
  • Exceptional written and oral communication abilities
  • Strong analytical and critical thinking skills
  • Ability to anticipate and make correct decisions in a fast-paced, dynamic environment
  • Ability to focus on multiple projects and re-establish priorities as necessary
  • Ability to work effectively with clinical, operational, and IT staff at all levels of the organization
  • Desire and ability to train and mentor team members
  • Ability to facilitate and work within a complex, multi-site environment.

At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong.  As relentless as we are in our mission to reduce the burden of cancer for all, we are equally committed to diversifying our faculty and staff.  Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.

Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.

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