Job Description

Location: New England Sinai Hospital
Posted Date: 3/9/2023

About Steward Health Care
Nearly a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country’s largest physician-led, tax paying, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.
Steward is among the nation’s largest and most successful accountable care organizations (ACO), with more than 5,500 providers and 43,000 health care professionals who care for 12.3 million patients a year through a closely integrated network of hospitals, multispecialty medical groups, urgent care centers, skilled nursing facilities and behavioral health centers.
Based in Dallas, Steward currently operates 39 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, Texas, and Utah.
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At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.

We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.

In support of this, we commit ourselves to the following values:






If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.

Summary of Responsibilities:

The Quality and Regulatory Manager is responsible for coordinating all aspects of the quality assessment and performance improvement program for all NESH services. The Quality and Regulatory Manager will assure compliance with CMS, DPH, Joint Commission and BORM standards through staff education, ongoing monitoring, and committee activities. Implements and monitors the Quality and Safety Plan consistent with board approved plans and regulatory and standard setting agencies. Coordinates all required regulatory reporting for DPH, BORM and Joint Commission. Actively promotes high reliability and leads efforts towards zero harm.


Minimum Education: RN preferred, other clinical background or comparable competence, to provide for appropriate oversight of quality programs. Bachelor of Science in Health Care related field and Master’s degree required.

Minimum Experience:

  1. Three to five to years’ experience within a hospital setting with a focus on quality management and regulatory compliance.
  2. Experience and/or demonstrated understanding of root cause analysis and FMEA analysis.
  3. Experience in statistical analysis tools with ability to analyze data, formulate meaningful information.
  4. Must possess expert knowledge of CMS, Joint Commission and DPH requirements as well as quality improvement tools/methods.

Minimum Skills/Abilities:

  1. Strong organizational skills.
  2. Strong interpersonal skills, ability to work across disciplines.
  3. Ability to analyze data, formulate meaningful information.
  4. Ability to work with, develop, motivate multi-disciplinary performance improvement team.
  5. Strong orientation to patient care in accordance with the hospital’s values, and our multidisciplinary approach to care.
  6. Ability to work with highly sensitive and confidential information with appropriate discretion.
  7. Able to communicate verbally and in writing in the English language.
  8. Strong computer and database skills
  9. Ability to manage multiple competing priorities.

Certification/Licensure: CPHQ designation desirable.

Training: Training in patient safety or and quality/performance Improvement methodology, concepts, education and implementation.

Special Qualifications: Membership and active participation in professional organization(s). IV.

Steward Health Care is proud to be a minority, physician owned organization. Diversity, equity, inclusion and belonging are at the foundation of the care we provide, the community services we support and all our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, and or expression or any other non-job-related characteristic.

Application Instructions

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