Assistant Vice President, Regulatory Compliance & Quality Improvement

Polaris Placement, LLC; New York (NY); On-site; USD 180,000 - 240,000; Full time

Job summary

The Bronx-based academic medical center seeks a senior leader to own regulatory compliance, quality assessment & improvement, and credentialing across three departments within a safety-net health system serving a dynamic patient population. You’ll report to the President & CEO and guide a team to ensure readiness and accountability.

In this role you’ll ensure alignment with Joint Commission, CMS, NYS DOH, and NYC Health Code standards, drive board-level reporting, and partner with

Qualifications

• 8–10 years of progressive experience in regulatory compliance or quality improvement.
• RN license strongly preferred; MPH or equivalent experience also considered.
• Master's degree in Business Administration, Public Administration, or Public Health Administration required.

Responsibilities

• Lead three departments: Regulatory Compliance, QA&I, and Credentialing within a major health system.
• Direct survey preparation and act as go-to advisor for Joint Commission, CMS, NYS DOH, and NYC Health Code requirements.
• Oversee QA&I program end-to-end, annual updates, and cross-department integration.
• Oversee credentialing with a Director and team to ensure audit readiness.
• Present quarterly reports to the Board of Trustees and Medical Board; collaborate with SVP of Hospital Operations.

Skills

Regulatory compliance

Quality improvement

Leadership

Regulatory language

Education

Master's degree in Business Administration

Master's degree in Public Administration

Master's in Public Health Administration

Job description

You didn't spend a decade building regulatory and quality expertise just to sit in the room where decisions get made about your work — you built it to be the person making them.

You're the one who reads a proposed CMS rule change and already knows which three departments it'll touch. You've sat through enough surveys to know the difference between a real deficiency and a documentation gap. And somewhere along the way, you started thinking less about passing the next survey and more about building a program that never has to scramble for one.

This is that seat.

Why This Role Is Different

This isn't a compliance role bolted onto a bigger title. It's full ownership of three departments — Regulatory Compliance, Quality Assessment & Improvement, and Credentialing — inside a well-established academic medical center and safety-net health system serving one of the most dynamic patient populations in the country.

Translation? You're not managing a checklist. You're running the infrastructure that keeps a major hospital system accountable to JCAHO, CMS, NYS DOH, and NYC Health Code standards — with a Credentialing Director and team already in place to execute, and a direct line to the CEO instead of three layers of approval in between.

The person leaving this seat held it for over 20 years. That's not a red flag — that's a runway. You're inheriting a program with real institutional memory, not one you have to rebuild from scratch.

What You'll Actually Be Doing

At the core, you're the person who makes sure regulatory readiness isn't a fire drill — it's a standing state.

You'll direct all survey preparation across the organization and serve as the go-to advisor when anyone — administration, medical staff, operations — needs to understand what Joint Commission, CMS, NYS, or NYC health code actually requires. When gaps surface, you're the one coordinating the corrective action plan and making sure it actually closes.

On the quality side, you'll own the hospital's QA&I program end to end — updating it annually, integrating activity across departments so nobody's duplicating work, and sitting as an ex-officio voice on the committees where quality decisions get made, from surgical case review to blood usage to medical records review.

You'll also oversee Credentialing — working through the department's Director and a team of three associates to keep practitioner credentialing and privileging processes tight and audit-ready. You're not doing the file-by-file work yourself; you're making sure the team doing it has what it needs and stays aligned with everything else moving through your world.

Then there's the reporting relationship that matters most: quarterly presentations to the Board of Trustees and Medical Board, covering everything from IPRO activity and DOH survey outcomes to incident reporting, patient satisfaction, and risk management. Day to day, you'll work closely with the SVP of Hospital Operations — especially when an agency inspection is underway and everyone needs the same playbook.

And beyond the reports and the readiness, you'll train the people around you — leading new-hire orientation on quality management and making sure staff across the organization understand the standards they're accountable to, not just the ones written in a policy binder.

The Kind of Leader Who Thrives Here

This role is built for someone who is:

• Comfortable moving between boardroom presentations and the details of a corrective action plan
• Fluent in regulatory language — JCAHO, CMS, DOH — without losing sight of the patient care it's protecting
• Experienced leading quality, compliance, or credentialing functions in a hospital or health system setting
• The person others call when a survey is imminent and everyone needs a clear head in the room
• Direct and organized, with the judgment to know which findings need escalation and which need a fix

You likely bring 8–10 years of progressive experience in regulatory compliance or quality improvement. An RN license is strongly preferred, consistent with the background of the person stepping out of this seat — though candidates with an MPH or otherwise directly relevant experience will also be considered. A master's degree in Business Administration, Public Administration, or Public Health Administration is required.

Schedule & Structure

This is a full-time, onsite leadership role based in the Bronx, reporting directly to the President & CEO. Oversight includes the Credentialing department, led day-to-day by a Director managing a team of three associates.

Compensation for this role is very competitive. Beyond compensation, you'll be joining an organization that combines the scale and teaching mission of an academic medical center with the mission and community impact of a safety-net health system — a place where the work you do is genuinely felt by the population it serves.

Bottom Line

If you're ready to lead the full regulatory, quality, and credentialing function for a major health system — with direct CEO access, board-level visibility, an established team already in place, and a program built on two decades of institutional foundation — this is a rare opportunity to run the whole picture, not just a piece of it.