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Marketing Statement

Elmhurst Hospital Center (EHC) is the major tertiary care provider in the borough of Queens. The hospital is comprised of 545 beds and is a Level I Trauma Center, an Emergency Heart Care Station and a 911 Receiving Hospital. It is the premiere health care organization for key areas such as Surgery, Cardiology, Women's Health, Pediatrics, Rehabilitation Medicine, Renal and Mental Health 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 Description

• Provides strategic regulatory leadership and leads the day-to-day operations of the department and regulatory and compliance programs, following guidelines and regulatory requirements and monitors the overall effectiveness of the program and departmental activities.
• Partners with senior leadership and other key stakeholders to define the strategic direction and operational plan for advancing regulatory and compliance programs, ensuring alignment with the System’s mission, values, and business goals.
• Develops and implements quality assurance initiatives and related services to ensure compliance with regulatory mandates, and establishes program and service goals and priorities. Identifies problems affecting the delivery of services and recommends and/or implements standard, cost-effective measures for service improvement.
• Investigates and reviews regulatory complaints and other related issues and coordinates correction and/or resolution, conducting follow-ups to ensure effective and timely resolution of complaints and implementation of appropriate control measures, as recommended.
• Conducts ongoing review of existing patient and public safety policies, procedures, standards and credentialing activities and other related standard operating procedures to identify barriers to success, gaps or discrepancies and recommends workable and cost-effective solutions or revisions, in consultation with appropriate staff.
• Conducts research and studies to identify and analyze compliance trends in regulatory affairs and may participate in special studies on quality and in other regulation-related areas. Oversees and/or participates in various committees, assessing and predicting changes in risk and regulation.
• Compiles, reviews and interprets risk, regulatory and compliance data, and presents key findings to various committees and other stakeholders and creates strategies and recommendations for interventions and appropriate control measures.
• Serves as a principal advisor and key resource to senior leadership and other parties, and as liaison between appropriate agencies and departments on all matters pertaining to patient and public health regulations, compliance, quality of care and patient safety and other matters relating to regulatory excellence.
• Ensures new regulations are disseminated throughout the health care setting and are implemented in appropriate departments. Partners with senior leadership to develop and maintain alert monitoring and reporting procedures and to create strategies and action plans to address potential regulatory concerns, reduce the likelihood of noncompliance and lessen the impact of related risks if/when they occur.
• Assists in the development of training programs and provides orientation, training, and guidance to staff. Routinely assesses staff learning needs identifying gaps and evaluating the quality and effectiveness of the training programs. Implements necessary changes in training and development to maximize productivity, effectiveness and efficiency of staff.
• Investigates incidents involving noncompliance with guidelines/procedures, and promptly reports to appropriate local, state and federal public health and regulatory agencies. Analyzes and documents accidents and incidents, utilizing appropriate tools and other applicable methods of analysis, to identify contributing factors and other safety concerns.
• Prepares and/or actively participates in the development of the fiscal year expense, revenue and operating budgets. Ensures operations run within budgetary guidelines, reviews budget requests for regulatory services and monitors all regulatory-related expenses and purchases.
• Coordinates all regulatory and accrediting agency audits and inspections, leading the department’s survey preparation efforts and maintains and continuously assesses regulatory survey readiness and ensures timely submission of corrective actions plans and implementation of corrective actions, when required.
• Provides post-survey recommendations for sustainable safety initiatives. Maintains an Environment of Care under accreditation standards by ensuring ongoing maintenance of all required departmental regulatory accreditations.
• Ensures ongoing compliance and maintenance of the NYC Health + Hospitals policies and procedures with national standards and other applicable external regulatory requirements, guidelines and accreditation authorities, as well as safety and quality management standards.
• Participates in internal/external quality assurance/performance improvement (QA/PI) activities, programs, and training, as required.
• Performs other related duties and participates in special projects, as directed.

Minimum Qualifications

• Juris Doctor degree from an accredited school of law, admission to the New York State Bar (NYS Bar), and five
• 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

• 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

• 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

• A satisfactory equivalent of education, training and/or experience.

Department Preferences

How To Apply

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 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