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NYC Health Hospitals

Director of Regulatory Affairs

NYC Health Hospitals, New York, New York, us, 10261


Lincoln Medical and Mental Health Center is one of New York City's premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women's Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.

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.

Visit us at www.nyc.gov/html/hhc/lincoln.

Job Description

Purpose of Position:

The Director of Regulatory Affairs oversees the daily operations of the Regulatory Affairs Department of Lincoln Medical Center and ensures that compliance and patient safety goals of NYC Health and Hospitals are met by performing and managing regulatory, accreditation, and performance improvement activities. Develops optimal strategies throughout the regulatory process. Serves as a proactive change agent promoting regulatory readiness, and assists in the integration of standards and requirements into the department. Ensures the delivery of patient-centered, cost-effective, quality services across the continuum of care, optimal utilization of resources, and ongoing compliance with applicable local, state, and federal rules, regulations, and security standards.

Responsibilities include the following:

Provides strategic regulatory leadership and leads the day-to-day operations of the regulatory program, following guidelines and regulatory requirements, and monitors the overall effectiveness of 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.Develop and implement quality assurance initiatives and related services to ensure compliance with regulatory mandates, and establish 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.Investigate and review regulatory complaints and other related issues and coordinate 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.Compiles, reviews, and interprets risk, regulatory, and compliance data, 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, patient safety, and other matters relating to regulatory excellence.Ensures new regulations are disseminated throughout Lincoln Medical Center 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 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.Investigate 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 maintains and continuously assesses regulatory survey readiness, and ensures timely submission of corrective action plans and implementation of corrective actions, when required.Provides post-survey recommendations for sustainable safety initiatives. Maintains Environment of Care regulatory standards by ensuring ongoing maintenance of all required departmental regulatory accreditations.Minimum Qualifications1. 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 healthcare compliance, regulatory affairs, risk and quality management and/or in similar areas; or2. 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; or3. 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; or4. 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 or forward your resume, noting the above Job ID #, to:

Lincoln Medical & Mental Health CenterHuman Resources Department234 Eugenio Maria De Hostos Blvd, (East 149th Street),2nd Floor, AnnexBronx, NY 10451Attn: Recruitment Unit

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