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 and 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 at SBELIH. Serving 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.

Job Duties & Essential Functions:

• 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.
• Identify and assess organizational risks related to patient safety, operations, legal liability, and compliance. Track, analyze, and report on risk trends and mitigation strategies.
• Participate in the investigation and analysis of safety events, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and near misses.
• Coordinate with leadership on risk exposure, claim management, and safety event documentation.
• Manage data integrity and validation processes for quality and compliance reporting, using platforms such as Medisolv, Vizient, and SB SAFE.
• Ensure timely submission of mandated data to external agencies.
• Manage and support processes related to insurance denials and appeals, including analysis, documentation, and coordination with relevant departments to ensure appropriate and timely resolution in accordance with payer requirements and organizational policies.
• Oversee the receipt, investigation, and resolution of patient and family complaints and grievances. Ensure that all concerns are addressed in a timely manner, documented appropriately, and resolved in accordance with hospital policy and regulatory requirements.
• Represent the Quality and Regulatory Affairs team on assigned hospital committees and workgroups.
• Promote a culture of transparency, accountability, and continuous improvement aligned with SBELIH’s I.C.A.R.E. values.
• Ensure departmental compliance with hospital policies, participate in policy review committees, and contribute to internal training efforts, including in-service programs and annual recertification.
• Maintain current knowledge of applicable healthcare laws, regulations, and best practices in quality, risk, and compliance.
• Adhere to all hospital and departmental policies and procedures.

• Perform other related duties as assigned by the Vice President.

   

Required Experience & Qualifications: 

• 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.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• 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, presentations, and telephone or virtual conferences.

• Occasional travel between campus locations and attendance at off-site meetings or regulatory activities.

   

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of SBELIH.

Special Notes: Resume/CV should be included with the online application.

• Stony Brook Medicine is a smoke-free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions may be subject to changes in pass days and shifts as necessary. 
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair. 
• This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook Eastern Long Island and related facilities.

Anticipated Pay Range: 

The starting salary range (or hiring range) for this position has been established based on relevant experience. The above salary range (or hiring range) represents SBEILH’s good faith and reasonable estimate of the range of possible compensation at the time of posting. 

Your total compensation goes beyond the number in your paycheck! 

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Eastern Long Island’s Employee Health Services *
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre-employment screenings.

• Provide a copy of any required New York State license(s)/certificate(s).

   

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer. 

*The Human Resources department will be responsible for any fee incurred for examination.
 

Company Overview:

As part of Stony Brook Medicine, Stony Brook Eastern Long Island Hospital (SBELIH) combines the best in academic and community medicine, improving access to advanced medical care for residents of the North Fork and Shelter Island. With 70 beds, SBELIH is Suffolk County’s first hospital, serving the North Fork since 1905. SBELIH provides care to 25,000 year-round residents and expanding to 60,000 summer residents with comprehensive healthcare solutions, including behavioral health, medical-surgical, orthopedics and general surgery, wound care, interventional pain management and GI, advanced ambulatory care, diagnostic, and physical therapy services. The hospital is also a clinical campus and training site for Stony Brook Medicine, with its first SBELIH Psychiatry resident having graduated in 2022.

StaffCo is a Professional Employer Organization, commonly referred to as a PEO, duly organized and registered under the New York Professional Employer Organization law.  StaffCo and SUNY have entered into a professional employer agreement under which StaffCo is the employer of Stony Brook Eastern Long Island employees and responsible for all aspects of employment, including hirings, promotions, disciplines, terminations, the day-to-day direction and supervision of work, as well as labor relations and collective bargaining. StaffCo is fully responsible for providing all payroll and human resources services, including the payment of wages, collecting and reporting payroll taxes and maintaining any and all employee benefits.  SUNY Stony Brook Hospital is responsible for the operation of the hospital and provision of health care and is the co-employer as is necessary to conduct its responsibilities and for related licensure, regulatory or statutory requirements and obligations.     

Given StaffCo’s employment responsibilities, it is deemed the “employer” for employment and labor law purposes.   Thus, the employees are private sector employees of StaffCo, not public sector employees of SUNY.   The private sector nature of the StaffCo employees has been approved by NYS Civil Service and upheld in a decision by the US National Labor Relations Board. 

Stony Brook Medicine is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

Stony Brook Eastern Long Island Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.