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About the Role
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. 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 requires hands-on experience interpreting and applying CMS conditions of participation, NYSDOH regulations, and JC standards within an acute care hospital setting. Act as a trusted advisor and subject matter expert to strengthen compliance, mitigate regulatory risk, and foster a culture of safety, quality, and continuous improvement.
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
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
- 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
- All employees should live within a commutable distance to NYP
- NYP will not reimburse for travel expenses
Skills
- Strong understanding of hospital operations, accreditation, and regulatory compliance
- Hands-on experience interpreting and applying Centers for Medicare and Medicaid Services (CMS) conditions of participation
- Hands-on experience interpreting and applying New York State Department of Health (DOH) regulations
- Hands-on experience interpreting and applying Joint Commission (JC) standards within an acute care hospital setting
- 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
- 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
Location
- New York, New York
Work Type
- Full-Time
- On-site
Experience Level
- Minimum 5 years of experience in healthcare
- 3+ years of project management experience
Education Level
- Bachelor's degree or equivalent experience
- Master's degree in a related field
Salary/Compensations
- $92,000-$152,500/Annual
Benefits
- Comprehensive and competitive benefits that support you and your family in every aspect of life
- Amazing benefits
- Countless opportunities for personal and professional growth
About the Company
- Experience the Pride of a Quality-Driven Career
- At NewYork-Presbyterian Hospital, every day is an opportunity to elevate the standard of care.
- Our state-of-the-art environment empowers continuous improvement, innovation, and collaboration.
- With an unwavering commitment to quality excellence, we remain one of the nation’s top hospitals – enhancing processes, supporting our teams, and delivering exceptional outcomes for patients.
- Join a healthcare system where employee engagement is at an all-time high.
- Here we foster a culture of respect, belonging, and inclusion.
- Join our team and discover where amazing works.
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Equal Opportunity
- NewYork-Presbyterian Hospital is an equal opportunity employer.