Overview
Responsible for leading and sustaining the organization's enterprise-wide policy and procedure management framework. This role establishes standardized governance, lifecycle management, and oversight for enterprise-level policies, while coordinating and providing oversight for local market policies maintained by market-based teams.
Positioned within the Transformation Office, enables consistent, scalable policy governance that supports regulatory readiness, accreditation requirements, and operational efficiency across a multi-market healthcare system. The role partners closely with clinical, operational, compliance, legal, quality, and IT leaders to ensure enterprise alignment while respecting necessary local variation driven by market-specific accreditation, regulatory, and operational needs.
Responsibilities
Key Responsibilities:
Enterprise Policy Governance & Program Leadership
- Leads the Enterprise Policy Management Program (EPMP), serving as the system-level authority for policy governance, standards, and lifecycle management
- Defines and maintains the enterprise policy governance framework, including decision rights, escalation pathways, approval structures, and accountability models
- Establishes criteria to differentiate enterprise, market, and departmental policies, ensuring appropriate ownership and governance
- Facilitates enterprise policy workgroups and coordinates executive-level reviews and approvals
Policy Lifecycle Management & Standardization
- Oversees the end-to-end lifecycle of enterprise policies, including intake, development, review, approval, publication, revision, and retirement
- Develops and maintains standardized templates, naming conventions, taxonomy, metadata, and governance requirements
- Provides guidance to local markets on policy lifecycle best practices while supporting necessary regulatory and accreditation flexibility
- Leads efforts to identify and consolidate duplicative, conflicting, or outdated policies
Oversight of Local Market Policies
- Establishes oversight mechanisms for local policy management, including minimum standards, reporting expectations, and review cadence
- Partners with market policy owners to ensure alignment with enterprise standards while respecting local governance needs
- Serves as the escalation point for enterprise-local policy alignment issues and cross-market impacts
Systems, Reporting & Regulatory Readiness
- Serves as the business owner for enterprise policy management systems, ensuring workflow standardization, version control, auditability, and reporting capabilities
- Defines and monitors key policy metrics, including review timeliness, approval cycles, policy inventory health, and consolidation progress
- Supports regulatory surveys, audits, and accreditation readiness by ensuring policies are current, accessible, and traceable
People Leadership & Operational Management
- Leads and develops Enterprise Policy Analysts/Coordinators, including performance management, coaching, and professional development
- Establishes standard processes for policy intake, editing, workflow coordination, publishing, and reporting
- Optimizes resource allocation to support enterprise initiatives and market needs
Change Management & Stakeholder Engagement
- Leads enterprise change management efforts related to policy governance, including communication, training, and adoption strategies
- Serves as a trusted advisor to clinical, operational, and administrative leaders on policy governance best practices
- Builds strong cross-market partnerships to drive consistency, adoption, and continuous improvement
Qualifications
Minimum Requirements:
Education:
Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Nursing, Quality, Compliance, Legal, Information Systems, or a related field
Experience:
- Minimum of 5 years of experience in healthcare policy management, regulatory compliance, quality/accreditation, governance, or related operational roles
- Demonstrated experience leading enterprise-wide or cross-functional programs within a complex, multi-site healthcare environment
- Experience with policy or document lifecycle governance, including approvals, version control, and review cycles
- At least 2 years of people leadership experience or equivalent responsibility leading teams or formal programs preferred
Licensure/Certifications (if applicable):
- OCEG IPMP (Integrated Policy Management Professional) or OCEG GRCP (GRC Professional) preferred
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