Director of Regulatory Affairs (00042773) Q

11 Jun, 2020


Director of Regulatory Affairs (00042773) Q

NYC Health & Hospitals
Queens, NY

Marketing Statement

Queens Hospital Center is making good on its promise to the people of southeastern and central Queens to maximize both patient convenience and positive clinical outcomes. Residents of Queens can count on the delivery of quality medical care right in their own borough.  In 2002 the hospital opened a state-of-the-art, 261-bed facility that includes the Queens Cancer Center, the first comprehensive cancer treatment center in the borough.

Job Description

Under supervision of the Associate Executive Director for Regulatory Affairs/ Performance Improvement and in collaboration with the Deputy Medical Director for Quality Assurance/ Performance Improvement, the Director of Regulatory Affairs position provides for coordination of hospital wide and Regulatory compliance.

The Director of Regulatory Affairs provides expertise in the areas of accreditation and regulatory compliance. A key responsibility is to develop, direct and implement strategies to achieve Regulatory Compliance. This position is responsible to ensure continuous readiness for surveys by The Joint Commission (TJC), the New York City/State Department of Health, the Centers for Medicare and Medicaid Services (CMS), and other external regulatory bodies as needed:

  1. Work in collaboration with all disciplines to ensure policies, procedures, and practices are compliant with TJC and regulatory standards.
  2. Maintain the organization’s Administrative Policy and Procedure manuals, utilizing the Ellucid Policy Management System; reconcile departmental policies with hospital wide policies. Research literature, evidence based practice and best known practices to develop content, tools, and resources for policies and procedures.
  3. In-servicing and education of hospital staff on new policies and procedures related to Joint Commission, CMS standards as well as City and State regulatory guidelines.
  4. Assist and act as a resource to assigned committees and assist in education and training for management and staff. Provide oversight of ongoing education and interpretation of standards and the survey process to all levels of staff.
  5. Performance of hospital wide patient/ system tracer activities to assess organizational compliance with accreditation standards and regulations in order to identify areas of vulnerability that are in need of improvement.
  6. Survey document preparation.
  7. Assist in responding to regulatory agency statement of deficiencies or requests for information in coordination with appropriate department directors.
  8. Assure that plans of correction address identified deficiencies and focus on systems improvements.
  9. Assist with completion of yearly Joint Commission Intracycle Monitoring.
  10. Assist in preparation of the quarterly QA Board Report and Semi-Annual and Annual Governing Body reports.
  11. Participate in accreditation seminars and activities to maintain current competency with regulatory standards and effective compliance strategies.
  12. Disseminate educational material regarding standards interpretations, changes in requirements and survey process changes on an ongoing basis to key stakeholders in the organization, including department heads and senior leadership.

Minimum Qualifications

 Bachelor’s degree in Nursing or related healthcare field required, Master’s degree preferred.
 Strong healthcare leadership with demonstrated experience in leading complex projects involving various stakeholders to achieve clinical excellence.
 Previous experience in a regulatory role including interactions with regulatory agencies (as lead regulatory representative), decision making and demonstrated ability to act independently.
 Current knowledge of and experience ensuring compliance with accreditation and regulatory standards such as Joint Commission, Center for Medicare and Medicaid (CMS),New York City/State Department of Health, and other regulatory agencies.
 Excellent verbal and written communication skills including presentation skills, as well as the ability to present to small and large audiences.
 Demonstrate professional confidence in his/her abilities and understanding of regulatory affairs and accreditation.
 A strong team player with communication and organizational skills to interact seamlessly both internally and externally.
 Establish policies and procedures as appropriate.
 Possess exceptional communication skills both written and verbal.

 Working knowledge of Federal, State, Local, Joint Commission and other Regulatory Agency standards.
 Effective interpersonal, verbal and written communication.
 Knowledge of and ability to perform statistical collection & analysis.
 Knowledge of and ability to perform Record Review.
 Ability to use computer and electronic software.

Learn more here

Job posted: 2020-06-11