AVP for Behavioral Health Quality and Regulatory Affairs

About the role

The Assistant Vice President (AVP) of Behavioral Health Quality and Regulatory Affairs oversees the quality, compliance, and performance improvement efforts across all Behavioral Health services. This role plays a critical role in ensuring the organization meets or exceeds regulatory standards set by various agencies.

Responsibilities

• 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, NYSJC, and other accrediting bodies.
• Coordinate Behavioral Health accreditation readiness activities, regulatory surveys, follow-up corrective actions, and continuous survey preparedness efforts.
• Provide oversight of all Behavioral Health regulatory compliance, ensuring alignment with OMH, OASAS, NYSJC, NIMRS, WISR, NYS Web Submission of Investigation Report, AARM NYS Administrative Action Reporting Mechanism, and DOH reporting requirements.
• Submit, complete, and monitor reporting into the NYSJC, NIMRS, and WISR as required.
• Respond to and manage timely submission of Behavioral Health incidents and sentinel events to required regulatory agencies.
• Provide supporting documentation including investigation reports, case reviews, and timelines to appropriate regulatory agencies in accordance with state and federal regulations.
• Track, trend, and implement policy and process changes in response to Behavioral Health regulatory updates, policy revisions, and documentation standards.
• Lead the development and implementation of Behavioral Health quality improvement initiatives and data-driven performance improvement plans.
• Participate in the investigation and analysis of Behavioral Health safety events, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and near misses.
• Identify and assess Behavioral Health risks related to patient safety, operations, legal liability, and compliance.
• Track, analyze, and report on risk trends and mitigation strategies.
• Lead Behavioral Health clinical case reviews to evaluate care delivery, identify risks, and recommend improvements.
• Analyze and report Behavioral Health quality metrics and CMS core measures (e.g., eCQMs, Core Measures) to inform program enhancements and risk mitigation strategies.
• Cook up with leadership on Behavioral Health risk exposure, claim management, and safety event documentation.
• Analyze data from SB Safe and other Behavioral Health quality sources to identify trends and opportunities.
• Monitor SB Safe incidents to ensure timely and accurate follow-up completion as per policy.
• Present SB Safe data to the Incident Review Committee (IRC), identifying trends and opportunities for safety enhancement.
• Manage and oversee the investigation, tracking, and resolution of patient and family complaints and grievances related to Behavioral Health services.
• Ensure grievance responses comply with regulatory requirements, including timeframes and documentation standards.
• Identify trends from Behavioral Health grievance data to inform performance improvement initiatives and report findings to the IRC.
• Provide support to Behavioral Health clinical teams in delivering care that meets standards for safety, quality, and evidence-based practices.
• Serve as a strategic partner to Behavioral Health leadership, Risk Management, Compliance, and other departments to foster a culture of safety, accountability, and excellence.
• Represent Behavioral Health Quality in meetings, hospital and system committees, workgroups, and during regulatory or accreditation surveys and audits.
• Promote a culture of transparency, accountability, and continuous improvement aligned with SBELIH’s I.C.A.R.E. values.
• Participate in policy review committees and contribute to internal Behavioral Health training efforts, including in-service programs and annual recertification.
• Maintain current knowledge of applicable healthcare laws, regulations, and best practices in Behavioral Health quality, risk, and compliance.

Qualifications

• Bachelor’s degree in nursing or social work required; with Master’s degree within five (5) years from an accredited college or university in Business/Healthcare Administration, Social Work, Nursing Leadership and Administration, Behavioral Health discipline or approved related program.
• Minimum of ten (10) years of combined clinical and administrative experience in a Behavioral Health setting.
• Knowledge of clinical documentation review and physician engagement strategies.
• Demonstrated success in managing and leading teams.
• Understanding of how Behavioral Health quality, regulatory compliance and risk management influence hospital-wide performance and patient safety.
• Knowledge of Behavioral Health regulatory standards (The Joint Commission, CMS, NYS DOH, OMH, OASAS, and the NYSJC), with experience ensuring compliance and readiness for surveys or audits.
• Experience initiating and executing Behavioral Health 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.