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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.


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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