AVP Quality and Regulatory Affairs

Position Summary

The Assistant Vice President (AVP) of Quality and Regulatory Affairs plays a vital operational leadership role in advancing hospital-wide efforts focused on quality, 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 ving 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.

• 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.
• Adhere to all hospital and departmental policies and procedures.
• Perform other related duties as assigned by the Vice President.

• Bachelor's degree in Nursing preferred; 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 five (5) 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.

• Primarily an office within a healthcare setting with an occasional exposure to patient care areas requiring adherence to hospital safety and infection prevention protocols.
• Ability to stand, walk, and move throughout the facility during meetings, audits, rounds, and regulatory reviews.
• Occasional lifting, carrying, pushing, or pulling of materials weighing up to 10 pounds (e.g., files, binders, laptop).
• Visual acuity sufficient for reviewing detailed documents, data reports, and regulatory materials, including use of a computer monitor for extended periods.
• Ability to hear and verbally communicate effectively in meetings,…