AVP for Behavioral Health Quality and Regulatory Affairs

The Assistant Vice President (AVP) of Behavioral Health Quality and Regulatory Affairs is a leadership role responsible for overseeing the quality, compliance, and performance improvement efforts across all Behavioral Health services. This position plays a critical role in ensuring the organization meets or exceeds regulatory standards set by the Office of Mental Health (OMH), the Office of Addiction Services and Supports (OASAS), the New York State Justice Center for the Protection of People with Special Needs (NYSJC), and the New York State Department of Health (DOH).

What You Will Do

Conduct Failure Mode Effects Analysis (FMEA's) and Root Cause Analyses (RCA's), including case reviews, deep dives, and corrective action plans for all Behavioral Health Services. Coordinate Behavioral Health accreditation readiness activities, regulatory surveys, follow-up corrective actions, and continuous survey preparedness efforts.

Why It Might Be a Fit

The AVP will be responsible for leading the development and implementation of Behavioral Health quality improvement initiatives and data-driven performance improvement plans. The ideal candidate will have a strong understanding of Behavioral Health regulatory standards and experience ensuring compliance and readiness for surveys or audits.

Requirements

• 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.

Benefits

• Smoke-free environment
• Paid time off
• Health insurance
• Retirement plan
• Learning budget
• Parental leave
• Wellness program
• Visa/relocation assistance
• Remote flexibility
• Stipends
• Bonus/commission
• Paid holidays