AVP Behavioral Health Quality and Regulatory Affairs

Job Description - AVP for Behavioral Health Quality and Regulatory Affairs (2602407)

The Assistant Vice President (AVP) of Behavioral Health Quality and Regulatory Affairs is a leadership role responsible for overseeing the quality, compliance, and performance improvement efforts across all Behavioral Health services. This position plays a critical role in ensuring the organization meets or exceeds regulatory standards set by the Office of Mental Health (OMH), the Office of Addiction Services and Supports (OASAS), the New York State Justice Center for the Protection of People with Special Needs (NYSJC), and the New York State Department of Health (DOH).

The AVP serves as a key advisor and subject matter expert in advancing behavioral health care quality, clinical effectiveness, and regulatory compliance. The AVP for Behavioral Health will be responsible for conducting Failure Mode Effects Analysis (FMEA’s) and Root Cause Analyses (RCA’s) including case reviews, deep dives and corrective action plans for all Behavioral Health Services. The AVP has responsibility for Behavioral Health quality improvement and risk reduction strategies.

• 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, NYSJC and other accrediting bodies.
• Coordinate Behavioral Health accreditation readiness activities, regulatory surveys, follow-up corrective actions, and continuous survey preparedness efforts.
• Provide oversight of all Behavioral Health regulatory compliance, ensuring alignment with OMH, OASAS, NYSJC, NIMRS, WISR NYS Web Submission of Investigation Report, AARM NYS Administrative Action Reporting Mechanism and DOH reporting requirements.
• Submit, complete and monitor reporting into the NYSJC, NIMRS, and WISR as required.
• Respond to and manage timely submission of Behavioral Health incidents and sentinel events to required regulatory agencies.
• Provide supporting documentation including investigation reports, case reviews, and timelines to appropriate regulatory agencies in accordance with state and federal regulations.
• Track, trend, and implement policy and process changes in response to Behavioral Health regulatory updates, policy revisions, and documentation standards.
• Lead the development and implementation of Behavioral Health quality improvement initiatives and data-driven performance improvement plans.
• Participate in the investigation and analysis of Behavioral Health safety events, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and near misses.
• Identify and assess Behavioral Health risks related to patient safety, operations, legal liability, and compliance. Track, analyze, and report on risk trends and mitigation strategies.
• Lead Behavioral Health clinical case reviews to evaluate care delivery, identify risks, and recommend improvements.
• Analyze and report Behavioral Health quality metrics and CMS core measures (e.g., eCQMs, Core Measures) to inform program enhancements and risk mitigation strategies.
• Coordinate with leadership on Behavioral Health risk exposure, claim management, and safety event documentation.
• Analyze data from SB Safe and other Behavioral Health quality sources to identify trends and opportunities.
• Monitor SB Safe incidents to ensure timely and accurate follow-up completion as per policy.
• Present SB Safe data to the Incident Review Committee (IRC), identifying trends and opportunities for safety enhancement.
• Manage and oversee the investigation, tracking, and resolution of patient and family complaints and grievances related to Behavioral Health services.
• Ensure grievance responses comply with regulatory requirements, including time frames and documentation standards.
• Identify trends from Behavioral Health grievance data to inform performance improvement initiatives and report findings to the IRC.
• Provide support to Behavioral Health clinical teams in delivering care that meets standards for safety, quality, and evidence-based practices.
• Serve as a…