Quality and Patient Safety Specialist

Job Title: Quality and Patient Safety Specialist (Joint Commission Tracer)

Location: New York, NY

Pay Rate: $65/hr

Schedule: Full-Time | Monday Friday | 9:00 AM 5:00 PM







Contract Duration: 17 Weeks

Required Qualifications

• Bachelor's Degree (Required)

• Master's Degree (Preferred)

• Minimum 5 years of experience, primarily in healthcare-related roles (Required)

• Quality Assurance experience is crucial

• Must have hospital healthcare experience

• Knowledge of Joint Commission, CMS, and DOH requirements and/or experience with Joint Commission or regulatory survey activity (Required)

• 3+ years of Project Management experience with the ability to plan and lead projects, facilitate project scope, develop project plans, manage timelines, and provide direction and support to project teams (Preferred)

• Advanced proficiency in Microsoft Outlook, Word, Excel, PowerPoint, and other web-based applications (Required)

• Experience with desktop computer applications and knowledge of database concepts

• Excellent verbal and written communication skills (Required)

• Experience managing and interpreting data (Required)

• Ability to manage multiple activities while meeting timelines and deadlines

• Ability to work effectively with a variety of departments and levels of personnel

Key Responsibilities

• Participate in hospital-wide continuous readiness activities to ensure ongoing compliance with Joint Commission, CMS, and DOH requirements.

• Serve as a subject matter expert for hospital teams assessing compliance with Joint Commission and other regulatory standards.

• Collaborate with departments, service lines, operations, and clinical units to implement standardized accreditation and regulatory processes.

• Assist hospital teams in assessing compliance with Joint Commission and other regulatory standards and requirements.

• Facilitate the development, monitoring, and analysis of corrective action plans and related data.

• Lead continuous readiness activities including tracer activities, internal mock surveys, focused standards assessments, training, education, and coordination with external consultants.

• Independently assess and respond to surveyor requests, review documentation, guide operational leaders, and determine escalation needs.

• Synthesize complex information for operational and senior leadership.

• Identify areas of regulatory risk.

• Review, interpret, and analyze hospital and departmental data to ensure compliance and monitor corrective action plans.

• Maintain current knowledge of Joint Commission, CMS, DOH, and other regulatory standards.

• Assess hospital policies, practices, and processes for compliance with new and existing regulatory requirements.

• Interpret regulatory standards and identify acceptable evidence of compliance.

• Serve as liaison between hospital leadership and surveyors, coordinating responses and documentation.

• Design and deliver educational training programs on accreditation and regulatory requirements.

• Present regulatory risks and mock survey findings to department leadership and senior management.

• Participate in hospital regulatory programs as survey escort, survey runner, and tracer participant.

• Manage Focused Standards Assessment (FSA) teams, identify risks, and collaborate on corrective action plans.

• Maintain the central repository of hospital survey activities and provide regulatory reports to leadership.

• Participate in hospital quality committees, work groups, and enterprise-wide quality initiatives.

• Project manage one or more quality goals annually.

• Perform daily monitoring of the Joint Commission secure extranet site for clinical alerts, process updates, and survey notifications as assigned.

• Perform other job-related duties as assigned.