Harlem Hospital Center has been a bedrock of the Harlem community since 1887. The hospital provides a wide range of medical, surgical, diagnostic, therapeutic and family support services to the residents of Central Harlem, West Harlem, Washington Heights and Inwood. Harlem is the largest hospital in the area, capable of treating the most seriously ill. Harlem provides over 90 specialized ambulatory care services, dentistry and oral surgery, behavioral health services, and community substance abuse treatment.

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.

Duties & Responsibilities

Facilitates and/or coordinates regulatory agency surveillance activities including survey preparations, accompaniment, reporting, and corrective actions. Monitoring activities to ensure compliance with applicable standards, laws, rules and regulations; and collaborates with directors of service, administrators, department heads and others to achieve and maintain compliance with regulatory standards/ requirements. Provides program assistance to implement, and ensure consistent compliance with all new, revised and updated regulatory standards and requirements.

SUMMARY OF DUTIES AND RESPONSIBILITIES:

• Develops/implements a regulatory program in line with leading industry practices.
• Coordinates survey/inspection activities and acts as liaison with regulatory agencies.
• Collaborates w/departments to formulate/implement processes, plans of corrections and monitoring systems to track /monitor compliance with policies/procedures and regulatory requirements.
• Conduct and facilitate educational programs on regulatory standards/ requirements.
• Assist/coordinate/prepare reports for quarterly and biannual Quality Assurance Committee of NYCH+H Quality Assurance Performance Improvement (QAPI) report Provide status of compliance with regulatory surveys, corrective actions and status of deficiencies.
• Coordinate hospital-wide monitoring activities to ensure compliance to accreditation/ regulatory standards requirements.
• Leads on-going preparation for TJC surveys, and facilitates preparations for other regulatory agency surveillance visits.
• Conducts audits on systems that may impede continued compliance and facilitate implementation of programs to ensure regulatory compliance.
• Participates actively in facility's commitment to patient safety goals.
• Review, interpret and advise on regulatory/accreditation standards, policies and procedures.
• Participates in root case analyses and clinical case reviews as assigned.
• Consults with departments to complete pre-survey applications, preparations for survey and addressing any potential deficiencies/citations.
• Prepares a summary of surveillance visits for senior staff to direct attention to expected citations for development and implementation of plans of correction.
• Maintains chronological records and files of all surveys, corrective action plans and compliance monitoring documents and submissions
• Monitors compliance with corrective action plans and prepares corrective action monitoring reports for Deputy Executive Director for cabinet and/or Hospital-Wide Performance Improvement Committee oversight.
• Responsible for remaining up to date on all regulatory standards and communicates any changes
• Prepares/reviews/revises policies/procedures for regulatory compliance, as required.
• Conducts periodic rounds to assess operational capacity and environmental condition of the facility.
• Acts as liaison with governmental and community agencies interacting with facility.
• Assists/responds to complaints from accreditation and regulatory agencies.
• Performs/assists with special projects as assigned.
• Attends committee/staff meetings and consults with medical and support services departments as assigned.
• Performs other duties/responsibilities as assigned.

Minimum Qualifications

1. Juris Doctor degree from an accredited school of law, admission to the New York State Bar (NYS Bar), and five (5) years of responsible experience in the practice of law following NYS Bar admission, in the fields of health care compliance, regulatory affairs, risk and quality management and/or in similar areas; or
2. Master's degree from an accredited college or university in Health Administration, Hospital Administration, Public Health, Business Administration or in a related health care specialization, and five (5) years of experience in compliance and regulatory affairs, risk and quality management, credentialing, leading and implementing performance improvement and process management programs and strategies, and performing other functions related to regulatory management in a hospital or a health care setting, three (3) years of which must have been in a responsible administrative, managerial or supervisory capacity; or
3. Bachelor's degree from an accredited college or university in fields, as described in "2" above; and seven (7) years of health care-related regulatory management experience, as described in "2" above, five (5) years of which must have been in a responsible administrative, managerial or supervisory capacity; or
4. A satisfactory equivalent of education, training and/or experience.

If you wish to apply for this position, please apply online by clicking the "Apply Now" button.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs