Assistant Director Transplant Quality and Regulatory

City/State:
Bronx, New York Grant Funded:
No Department:
Transplant
- Abdominal Administration

Work Shift:

Day Work Days: MON-FRI Scheduled

Hours:

8 AM-4:30 PM Scheduled Daily

Hours:

7.5 HOURS Pay Range: $-$

The Assistant Director of Transplant Quality & Regulatory is a subject matter expert responsible for directing and overseeing transplant quality, regulatory compliance, patient safety, and data management activities across the solid organ transplant programs. This role works collaboratively with physician, clinical, operational, and administrative leadership, as well as with Risk Management, Compliance, Information Technology, and Quality & Safety departments, to support regulatory readiness, performance improvement, and high-quality patient-centered care throughout the transplant continuum.

The Assistant Director oversees a comprehensive transplant quality and compliance program focused on adherence to all applicable regulatory and accreditation requirements, including those established by the Organ Procurement and Transplantation Network / United Network for Organ Sharing, Centers for Medicare & Medicaid Services, Scientific Registry of Transplant Recipients, and The Joint Commission. This includes oversight of quality assessment and performance improvement (QAPI) activities, patient safety initiatives, clinical performance metrics, regulatory audits and inspections, adverse event review, corrective action planning, and continuous process improvement initiatives.

This role provides strategic oversight and operational leadership for the transplant data management team, ensuring accurate and timely regulatory reporting, data integrity, dashboard development, analytics, and integration of transplant-related data across internal and external reporting systems including Epic Systems, Phoenix, UNOS, and SRTR platforms. The Assistant Director serves as a key resource to transplant leadership and is authorized to access all transplant program functions, records, and operational areas relevant to quality, compliance, and patient safety activities under review.

The position serves as a key driver in advancing a culture of regulatory excellence, accountability, innovation, interdisciplinary collaboration, and continuous quality improvement to support optimal patient outcomes and organizational performance.

• Oversee and monitor all aspects of the transplant quality and compliance program, including policies, procedures, and protocols.
• Develop and implement a comprehensive transplant quality and compliance program in accordance with regulatory standards and guidelines.
• Establish and implement written policies to identify report, analyze, and address transplant-related adverse events.
• Actively participates in Quality Review processes, Root Cause Analysis, case debriefings, and medical staff Morbidity & Mortality (M&M) meetings to assess situations to identify potential improvements and respond to grievances, patient complaints, regulatory inquiries.
• Conduct regular audits and reviews to ensure compliance with regulatory standards and identify areas for improvement.
• Collaborate with medical staff, administrators, and other stakeholders to develop and implement quality improvement initiatives.
• Facilitates solid organ transplant specific quality and P&P meeting structure, including but not limited to: scheduling, coordinating, developing agendas with the program directors, taking minutes as needed, distributing documents, preparing and presenting presentations, & ensuring accuracy and timeliness of information.
• Utilizes tools to track the following:
  Performance Improvement activities and CAPs, Adverse Events, Transplant Dashboards (Operational and Clinical outcomes), Patient Complaints, Policy Stat. Work together with Data team to keep tools up to date and to assess for accuracy.
• Responsible for accurate and timely submission of data to UNOS (TIEDI forms), Renal Network, and the timely review of data in the SRTR.
• Audit the integrity of data entered by the transplant teams to ensure regulatory compliance within our EMR EPIC of the Transplant Coordinators.
• Retrieves and integrates…