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Associate Director, Office of Accreditation & Regulatory Services

New York Full-Time
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Empower Every New Yorker — Without Exception — to Live the Healthiest Life Possible

Come join the largest public hospital system in the nation! Every day, we work together to make an extraordinary difference in the health and well-being of each individual we serve – without exception. Join our team and help us create a positive human experience.

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city’s five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

Responsibilities:

Reporting to the Assistant Vice President for Accreditation and Regulatory Services, the Associate Director provides consultative and on-site technical assistance to the NYC Health + Hospitals facilities on accreditation and regulatory requirements and compliance issues. The Associate Director also collects, aggregates and analyzes data that supports, and is critical to, NYC Health + Hospitals Continuous Readiness Program.

Responsibilities will include, but not be limited to:

  • Coordinate and participate in onsite NYC H+H facility mock surveys, reviews mock survey reports on findings and opportunities for improvement, and provides onsite technical assistance to facility staff
  • Review Plans of Correction to ensure compliance with federal, state and local requirements, standards and corporate policies and procedures
  • Collaborate with facility core measures liaisons and analyze core measure outcomes data for trends, benchmarking and performance improvement
  • Coordinate the patient safety culture survey
  • Develop, assess and review contracts
  • Draft, review, and/or recommend as necessary, updates policies and procedures based on new or revised changes in regulations and standards
  • Develop, prepare, revise, amend, and/or update survey tools and checklists used for assessing compliance
  • Keep current and informed on best practices, and maintain a thorough knowledge and understanding of regulatory and non-compliance trends
  • Develop, organize and coordinate training and educational programs for facility and central office staff on new and/or revised regulatory updates
  • Accountable for project deliverables and using lessons learned to inform improvement strategies
  • Track issues to resolution
  • Staff/convene/participate in meetings, task force and workgroups
  • Performs special projects and other duties as assigned
  • A Baccalaureate Degree from an accredited college or university in Health Administration, Public Administration or approved related program; and,
  • Six years of full-time, paid experience of progressively responsible level in hospital administration with particular emphasis on development and evaluation of health care delivery services; or,
  • A Master's Degree from an accredited college or university in Hospital or Health Administration, Health Care Planning, Public Health, Administrative Medicine, Business Administration, Public Administration or approved related program; and,
  • Five years of full-time, paid experience as indicated in (2); or,
  • A satisfactory equivalent combination of education, training and experience.

Recommended skills

Health Care
Public Administration
Patient Safety
Benchmarking (Project Management)
Review Contracts
Care Planning
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