Quality & Patient Safety Specialist - Regulatory
About The Position
In this highly visible role, you will serve as a trusted partner in supporting regulatory readiness, patient safety, and operational excellence across the NewYork-Presbyterian enterprise. This position is best suited for an experienced healthcare professional with a strong understanding of hospital operations, accreditation, and regulatory compliance. You will collaborate with clinical, operational, and administrative leaders to prepare for and respond to unannounced federal and state regulatory surveys, support enterprise-wide readiness initiatives, and drive performance improvement efforts. Success in this role requires hands-on experience interpreting and applying Centers for Medicare and Medicaid Services (CMS) conditions of participation, New York State Department of Health (DOH) regulations, and Joint Commission (JC) standards within an acute care hospital setting. As a trusted advisor and subject matter expert, you will help strengthen compliance, mitigate regulatory risk, and foster a culture of safety, quality, and continuous improvement across the organization.
Requirements
- Bachelor's degree or equivalent experience
- Minimum 5 years of experience in healthcare, with a focus on regulatory, quality and performance improvement
- Demonstrated experience working with CMS Conditions of Participation, Department of Health (DOH) regulations, and Joint Commission standards in an acute care healthcare environment
- Experience supporting regulatory surveys, accreditation activities, tracers, mock surveys, plans of correction, or ongoing regulatory readiness initiatives
- Experience managing, analyzing, and presenting quality, safety, or regulatory data to support decision-making
- Full-time position requires flexibility to travel across the NewYork-Presbyterian enterprise as needed.
- Flexibility is essential – particularly when working within the dynamic demands of the survey environment.
Nice To Haves
- Experience leading or actively participating in CMS, DOH, and Joint Commission healthcare regulatory survey activity
- Experience in a large academic medical center, hospital system, or multi-site healthcare organization
- Extensive knowledge of CMS Conditions of Participation, DOH regulations and connection to hospital operations and policies
- Expertise in organizational patient readiness, patient safety protocols, and quality improvement methodologies
- Master’s degree in a related field
- Clinical licensure (RN, NP, PA, RD, PT/OT, or PharmD) with hands-on experience and leadership in a hospital setting
- Project Management Professional (PMP) or Six-Sigma Lean certification
- 3+ years of project management experience, including leading cross-functional initiatives, managing timelines, and coordinating project teams
Responsibilities
- Support the hospital’s response to unannounced CMS and DOH surveys
- Provide on-site support throughout onsite survey activity
- Work with clinical teams to develop and implement post-survey plans of correction
- Support ongoing regulatory readiness efforts across multiple hospital sites
- Provide consultation, analysis, and improvement facilitation for quality, safety, and compliance initiatives
- Assess organizational compliance with CMS, DOH, and Joint Commission regulatory standards
- Collaborate with departments, service lines, and clinical teams to implement and sustain accreditation and regulatory processes
- Analyze internal and external quality and regulatory data to identify trends, opportunities, and strategic priorities
- Serve as a recognized resource for regulatory compliance
- Partner closely with Quality and Patient Safety colleagues across the enterprise as part of one integrated team
Benefits
- Comprehensive and competitive benefits that support you and your family in every aspect of life.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
