Aso Dir. Hlth Care Standards- Regulatory

Kings County Hospital Center has a rich legacy for its pioneering role in medicine. Today, with over 625 beds, our hospital remains on the cutting edge of technology and provides the most modern procedures with state-of-the-art equipment. Built in 1831 as a one room infirmary for publicly supported care of the sick, Kings County Hospital Center continues to be a leading healthcare facility whose mission is to provide care to everyone regardless of their ability to pay. The hospital provides a wide range of health services, and specialties are offered in all fields of modern medicine. More than 200 clinics provide a wide array of ambulatory care 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.

Work Shifts

Shift: 9:00am-5:00pm

Job Description

Purpose:
Under the supervision of the Director of Regulatory Affairs and Accreditation, the Associate Director ensures compliance with regulatory agencies such as the Department of Health and The Joint Commission. This role involves analyzing compliance issues, assisting in inspections, developing action plans, and ensuring regulations are up to date and effectively communicated.

Key Responsibilities:

• Serve as a regulatory and accreditation compliance expert.
• Collaborate with medical, nursing, and administrative departments to enhance patient safety and communication.
• Maintain knowledge of TJC, NYC Public Health Law, NYSDOH, CMS, and hospital policies.
• Support and coordinate logistics during regulatory surveys.
• Develop corrective action plans, track compliance findings, and report progress.
• Lead and support performance improvement initiatives, policy development, and workflow processes.
• Provide education on compliance standards to medical staff and hospital departments.
• Monitor compliance through audits, tracers, rounds, and mock surveys.
• Identify vulnerabilities and conduct risk assessments.
• Lead monthly ARCC meetings and oversee the AMP Tracer Tool software implementation.
• Assist in responding to regulatory inquiries and coordinating process improvements.
• Participate in regulatory affairs meetings, continuing education, and special projects.

Core Skills:

• Expertise in DOH, CMS, and TJC regulations.
• Strong data collection, analysis, and reporting abilities.
• Ability to manage multiple priorities and oversee project success.
• Excellent written and verbal communication skills.

Minimum Qualifications
1. Master's degree from an accredited college or university in Hospital, Health, Public or Business Administration, Healthcare Management, Public Health or a related discipline; and four (4) years of full-time, paid progressively responsible experience in hospital administration with an emphasis on the development and evaluation of health care delivery services; or
2. Bachelor's degree from an accredited college or university in disciplines, as listed in #1 above; and five (5) years of full-time, paid experience, as described in #1 above.

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

Vacancy Control Board Number

VCB #: KIN-02112025-0908