Associate Director, Quality Assurance

NYC Health + Hospitals/Bellevue is Americas oldest public hospital, established in 1736. Affiliated with the NYU School of Medicine, the 844-bed hospital is a major referral center for highly complex cases, with its 6,000 employees including highly skilled, interdisciplinary clinical staff. It sees more than 110,000 emergency room visits and 500,000 outpatient visits annually. Bellevue is an academic medical institution of international renown. We have served as an incubator for major innovations in public health, medical science, and medical education. Bellevue is a Level I Trauma Center delivering around-the-clock care in adult, pediatric, psychiatric and pediatric psychiatric emergencies as well as in the nationally-designated categories of cardiology, neurology, toxicology, and neonatology. In addition to providing comprehensive inpatient and outpatient state-of-the-art care Bellevue is a city-wide medical specialty referral source. Bellevues clinical centers of excellence include: Emergency Medicine and Trauma Care; Cardiovascular Services; Designated Regional Perinatal Center and Neonatal Intensive Care Unit (ICU); Comprehensive Childrens Psychiatric Emergency Program; and Cancer Services. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Job DescriptionArea of ResponsibilityIn collaboration with the Director of Regulatory, will be responsible for the monitoring and compliance with the state and federal regulatory requirements by building and maintaining a regulatory infrastructure that includes internal and external regulatory audits, drafting and implementing corrective action plans.Duties and Responsibilities:Direct the regulatory program that is aligned with Health + Hospitals triple aim.Provide support in the hospitals interaction with the New York State Department (NYSDOH)and assist as needed in activities related to interactions with federal, state and local regulatory terpret, implement and analyze Medicare/Medicaid Conditions of Participation (CoPs) and New York State Department of Health (NYSDOH) licensure and regulatory requirements, as to their correlation with Join Commission accreditation standards.Collaborate with leadership of Quality and Risk Management in monitoring and interpreting changes to Federal and State hospital regulations, and communicate with stakeholders throughout the hospital as to changes in these anize, manage and monitor the hospitals continual readiness for unannounced Joint Commission, CMS, etc. surveys and aid as needed in interactions with onsite surveys, inspections and investigations from any/all federal, state and local regulatory authorities.Utilize experience, external research and internal sources to identify and assist in remediating areas of non-compliance or vulnerability relative to Joint Commission standards and federal/state/local regulations.Draft and submit corrective action plans to external regulatory agencies. Track compliance of implemented corrective action plans.Manage, evaluate and implement hospital-wide and departmental performance improvement projects.Coordinate the implementation of corporate operating procedures and hospital-wide policies through policy database management.Manage corrective action plans to ensure compliance with stated policies, regulatory standards and current evidence-based practicesManage policy database to ensure, accuracy and compliance to regulations and best practiceCollaborate with clinical service line administrators in licensure applications relative to new programs, expansion, acquisition of certifications.Serve as Regulatory representative to hospital-wide service line and management meetings.Responsible for planning, content and presentations for ASPIRE meetingsOther duties as assignedMinimum QualificationsQualification for Health Care Facility. Baccalaureate Degree in Public Administration, Public Health or Health Care Specialization; and,Five* years or four# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services; orA Masters Degree in Public Administration, Public Health or Health Care Specialization; and, Four* years or three# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services. A minimum of three years clinical, regulatory or hospital management experience.Knowledge & Skills:• Extensive knowledge of federal, state, TJC, OMH and CMS guidelines/regulations• Excellent interpersonal and communication skills, (written and verbal) and analytical, problem solving and organizational acumen.• Ability to meet deadlines,If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.NYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs

Created: 2025-04-02