Lincoln Medical and Mental Health Center is one of New York City's premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women's Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.
Work Shifts8:00 A.M - 4:00 P.M; Monday to Friday
. *[35 Hours per Week.]Duties & ResponsibilitiesPurpose of Position:
Under supervision, assist the Chief Quality Officer / Director(s) of Quality Management/Regulatory Affairs in the day-to-day operations of the Quality Management Division, inclusive of scheduling interdepartmental and intradepartmental meetings, preparation of meeting-related materials, as necessary.
DUTIES AND RESPONSIBILITIES: - Responsible for the coordination, preparation, and timely submission of the quarterly Quality Assurance Performance Improvement (QAPI) Board of Directors report to the NYC H+H Board of Quality Assurance Committee.
- Responsible for the coordination, preparation, and timely submission of the Semi-annual & Annual Governing Body report to the NYC H+H Full Governing Body.
- Schedules and attends the Board Report review meetings, makes note of changes in the reports, reviews and edits/provides feedback on minutes, as well as items requiring follow-up till resolved.
- Plans, organizes, and assists in the preparation and management of inspections, accreditations, audits, and compliance reviews, ie: TJC Accreditation, Disease Specific Certification and Re-certification, CMS and DOH unannounced and announced visits, and other facility audits/visits as required.
- Sits in on meetings with various departments to collaborate on ways to integrate quality and regulatory standards into everyday practices, and coordinate efforts across teams to promote a culture of safety and excellence.
- Coordinates the preparation of the Accreditation and Regulatory Compliance Committee meetings.
- Compiles data/reports from unit rounds (Floor Monitor) into a computerized system.
- Guides departments in the creation and updating of policies and procedures to ensure alignment with regulatory requirements and quality standards; and ensures hospital-wide and departmental policies are in the correct format and sent to SharePoint for upload.
- Manages the collection of hospital-wide departmental Quality/Performance Improvement minutes.
- Manages budgets related to quality and regulatory programs, ensuring efficient use of resources and financial stewardship.
- Acts as a back-up to the Associate Director with CMS/TJC and all Quality Mandatory Reporting.
- Assist CQO and Director(s) of Quality Management / Regulatory Affairs with day-to-day administrative and operational functions as needed.
- Performs other related duties as assigned by the CQO and Director(s) of Quality Management / Regulatory Affairs.
- Acts as a liaison for the C-Suite, Finance, and Centralized Corporate Offices.
- Orients and provides training and guidance to staff.
- Assist in completing special projects as they unfold.
Minimum Qualifications1. A Baccalaureate Degree from an accredited college or university in Management, Industrial Engineering, Business Administration or an approved systems-related program; and,
2. Six years of full-time, paid experience in business, government, hospital, educational institution or a non-profit organization in the development, analysis and implementation of systems and subsystems, manual and computer application, of which two years must have been in a supervisory, administrative or consultative capacity; or,
3. A Master's Degree from an accredited college or university in the programs in (1); and,
4. Five years of full-time, paid experience as indicated in (2), with one year required at the supervisory, administrative or consultative level; or,
5. A satisfactory equivalent combination of education, training and experience.
Department PreferencesEducation
• Master's degree in Healthcare Administration (MHA), Public Health (MPH), Health Administration, Health Services Administration, or another closely related healthcare field.
• Clinical credentials or additional certifications in healthcare quality, regulatory compliance, patient safety, or accreditation are preferred but not required.
Professional Experience
• Minimum of 3 years of hospital-based experience in Quality Management, Regulatory Affairs, Accreditation, or Compliance.
• Demonstrated experience preparing for, participating in, and responding to regulatory and accreditation surveys.
• Experience developing and monitoring Plans of Correction (POCs), corrective action plans, performance improvement initiatives, and ongoing regulatory readiness activities.
Regulatory & Accreditation Knowledge
The preferred candidate should have working knowledge and practical experience with applicable regulatory and accreditation requirements, including:
• The Joint Commission (TJC) accreditation standards and survey readiness
• Centers for Medicare & Medicaid Services (CMS) Conditions of Participation
• New York State Department of Health (NYS DOH) regulations
• New York State Office of Mental Health (OMH) requirements
• New York State Office of Addiction Services and Supports (OASAS) requirements
• Regulatory tracers, audits, policy review, compliance monitoring, and continuous survey readiness
• Quality improvement, performance improvement, patient safety, and data-driven corrective action
Preferred Leadership Qualities
The ideal candidate will be highly organized, detail-oriented, collaborative, and comfortable working directly with clinical and operational leadership. The individual should be able to interpret regulatory requirements, identify compliance risks, communicate expectations clearly, and help departments translate regulatory standards into sustainable operational practices.
A strong candidate should also demonstrate the ability to lead regulatory readiness efforts, educate staff and leadership, manage competing priorities, and maintain a culture of continuous readiness rather than preparing only when a survey is approaching.
BenefitsNYC Health and Hospitals offers a competitive benefits package that includes:
- Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
- Retirement Savings and Pension Plans
- Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
- Loan Forgiveness Programs for eligible employees
- College tuition discounts and professional development opportunities
- College Savings Program
- Union Benefits for eligible titles
- Multiple employee discounts programs
- Commuter Benefits Programs
If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.
