Quality and Reg Program Assistant | SQM | Full Time

Job Duties And Responsibilities

• Maintain and manage the enterprise-wide quality and regulatory project tracker, including timelines, milestones, deliverables, and responsible parties.
• Track progress of quality improvement initiatives, regulatory action plans, and Joint Commission readiness activities.
• Cook up follow-up on assigned tasks from quality committees, regulatory surveys, and executive leadership meetings.
• Identify delays, barriers, and risks in project execution and escalate issues to the Senior Director of Quality & Regulatory Affairs.
• Support implementation tracking for corrective action plans related to audits, surveys, and performance improvement initiatives.
• Maintain documentation systems related to Joint Commission readiness, CMS compliance, and other regulatory requirements.
• Organize and support documentation for accreditation surveys, mock surveys, tracer activities, and compliance audits.
• Aid in preparing materials for regulatory reviews, board reports, and executive presentations.
• Optimize timely collection and organization of evidence required for accreditation and regulatory compliance.
• Cook up scheduling, agendas, materials, and minutes for quality, patient safety, accreditation, and population health committees.
• Track committee action items and ensure completion of assigned follow-ups.
• Maintain standardized documentation for committee structures, reporting workflows, and governance requirements.
• Aid in maintaining quality dashboards, spreadsheets, and tracking tools used for performance monitoring.
• Aid in maintaining the incident event reporting system and associated reports.
• Compile data from multiple departments to support reporting requirements for regulatory and quality programs.
• Support documentation standardization and administrative workflows across quality and regulatory functions.
• Ensure accuracy, consistency, and version control of quality and regulatory documents.
• Serve as a communication hub between clinical quality staff, regulatory teams, ambulatory and hospital leadership, and administrative departments.
• Distribute updates related to quality initiatives, regulatory requirements, and accreditation readiness activities.
• Facilitate timely communication of deadlines, deliverables, and regulatory requirements across departments.

Job Requirements

• Required Education: Associates or Bachelors Degree in Healthcare Administration, Business Administration, Public Health, or related field.
• Required Work Experience: 2–5 years of experience in healthcare administration, project coordination, quality support, regulatory compliance, or related field.
• Experience: Experience in a hospital, health system, or ambulatory care setting strongly preferred. Experience supporting quality improvement, accreditation, or regulatory programs is a plus.

Required Knowledge, Skills, And Abilities

• Strong organizational and project management skills.
• Ability to track multiple projects, deadlines, and priorities simultaneously.
• High attention to detail and accuracy in documentation and reporting.
• Strong communication and interpersonal skills.
• Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint) and project tracking tools.
• Ability to work effectively with clinical and non-clinical stakeholders.
• Understanding of healthcare operations, quality programs, or regulatory environments preferred.

Success Measures

• Timely and accurate tracking of quality and regulatory projects.
• Effective coordination of accreditation and regulatory documentation.
• Completion and follow-up of committee and action items.
• Improved organization and efficiency of quality and regulatory workflows.
• Reduction of administrative burden on clinical quality and leadership teams.
• Support of successful Joint Commission and regulatory survey readiness.

Organizational Expectations

• Provides a positive and professional representation of the organization.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
• Maintains hospital standards for a clean and quiet environment.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope-of-practice or job role.
• Participates in ongoing quality improvement activities.
• Maintains compliance with organization’s policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.
• Complies with organizational and regulatory policies for handling confidential information.
• Demonstrates excellent customer service through their attitude and actions, consistent with the standards contained in The Gritman Way.