AVP Quality and Regulatory Affairs

Stony Brook University•Greenport, NY

77d

About The Position

The Assistant Vice President (AVP) of Quality and Regulatory Affairs, plays a vital operational leadership role in advancing hospital-wide efforts focused on quality and performance improvement, regulatory compliance, risk mitigation, and performance excellence. Working closely with the Vice President, the AVP ensures alignment with local, state, and federal regulations while fostering a culture of safety, accountability, and continuous improvement at SBELIH. Serving as a strategic liaison among clinical, administrative, and operational teams, the AVP is responsible for executing quality initiatives, overseeing regulatory survey preparedness, and reinforcing the hospital's risk management and compliance infrastructure. The AVP also supports the day-to-day operations of the Quality and Regulatory Affairs Department, helping to ensure that all initiatives meet the standards set by The Joint Commission, CMS, the New York State Department of Health, OMH, OASAS, and other regulatory authorities.

Requirements

Bachelor's degree in Nursing required; with Master's degree within five (5) years from an accredited college or university in Business/Healthcare Administration, Quality and Patient Safety, Nursing Leadership and Administration or approved related program.
Minimum of ten (10) years of combined clinical and administrative experience in an acute hospital setting required.
Knowledge of clinical documentation review and physician engagement strategies.
Demonstrated success in managing and leading teams.
Understanding of how quality, regulatory compliance and risk management influence hospital-wide performance and patient safety.
Knowledge of The Joint Commission, CMS, NYS DOH, and other regulatory standards, with experience ensuring compliance and readiness for surveys or audits.
Experience initiating and executing improvement projects, using data to assess outcomes, and collaborating with multidisciplinary teams to sustain measurable change.
Understanding of incident reporting, event investigation, and proactive risk assessment from a clinical leadership perspective.
Strong interpersonal and written/verbal communication skills, with the ability to effectively engage with executive leadership, physicians, and support departments.
Skilled at using clinical and operational data to inform decisions; ability to interpret dashboards, identify trends, and contribute to strategic quality initiatives.
Ability to lead change, mentor staff through transitions, and promote a culture of accountability, transparency, and continuous improvement.

Responsibilities

Support the VP in managing daily operations of the Quality and Regulatory Affairs department to maintain compliance with The Joint Commission, CMS, NYS DOH, OMH, OASAS, and other accrediting bodies.
Coordinate accreditation readiness activities, surveys, follow-up corrective actions, and continuous survey readiness efforts.
Collaborate with clinical and administrative departments to design and implement performance improvement initiatives based on data analysis and regulatory priorities.
Assist in the coordination of physician performance improvement efforts, including professional practice evaluations, credentialing support, and reappointment profiling.
Monitor national and state performance metrics (e.g., Leapfrog, eCQMs, Core Measures) and support required reporting.
Identify and assess organizational risks related to patient safety, operations, legal liability, and compliance. Track, analyze, and report on risk trends and mitigation strategies.
Participate in the investigation and analysis of safety events, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and near misses.
Coordinate with leadership on risk exposure, claim management, and safety event documentation.
Manage data integrity and validation processes for quality and compliance reporting, using platforms such as Medisolv, Vizient, and SB SAFE.
Ensure timely submission of mandated data to external agencies.
Manage and support processes related to insurance denials and appeals, including analysis, documentation, and coordination with relevant departments to ensure appropriate and timely resolution in accordance with payer requirements and organizational policies.
Oversee the receipt, investigation, and resolution of patient and family complaints and grievances. Ensure that all concerns are addressed in a timely manner, documented appropriately, and resolved in accordance with hospital policy and regulatory requirements.
Represent the Quality and Regulatory Affairs team on assigned hospital committees and workgroups.
Promote a culture of transparency, accountability, and continuous improvement aligned with SBELIH's I.C.A.R.E. values.
Ensure departmental compliance with hospital policies, participate in policy review committees, and contribute to internal training efforts, including in-service programs and annual recertification.
Maintain current knowledge of applicable healthcare laws, regulations, and best practices in quality, risk, and compliance.
Adhere to all hospital and departmental policies and procedures.
Perform other related duties as assigned by the Vice President.