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Director of Regulatory and Accreditation in Brooklyn, NY at Pride Health

Date Posted: 5/26/2019

Job Snapshot

  • Employee Type:
  • Location:
    Brooklyn, NY
  • Experience:
    Not Specified
  • Date Posted:

Job Description

Brooklyn hospital seeks a Director of Regulatory and Accreditation to participates in monitoring, reporting, and improvement activities related to accreditation and regulatory requirements.


  • Serves as liaison with the Joint Commission (TJC), CMS, and State, City, etc., regulatory agencies and serves as a resource on regulation and accreditation to the staff.
  • Interpret any statement of deficiencies and preparation and implementation of the plans of correction
  • Plan, direct, and design programs to ensure continuous compliance with regulatory requirements and updates and educates the clinical and administrative staff.
  • Coordinate the survey preparedness teams, TJC unannounced in-house survey, and subsequent follow-up, as required, in addition to complaints from the TJC requiring investigation and response, including design, implementation and monitoring of compliance.
  • Responsible to coordinate the completion of regulatory surveys such as Leapfrog, Empire Q-HIP, AHRQ, Hospital-Acquired Condition Deficit Reduction Analysis and Present-On-Admission indicators program, and surveys associated with Quality Net, and regulatory agencies, etc.
  • Participate in the concurrent review of data with colleagues in infection control, performance improvement, risk, and patient safety.


  • Master’s Degree 
  • Five years of hospital administration experience  
  • Knowledge of fundamentals of healthcare facility organization, administration and standards, regulations and laws applicable to healthcare facility operations.