Description
**JOB DESCRIPTION**
A member of MSHS regulatory team, the Accreditation Specialist is a key leader and participant in the systems continuous accreditation and regulatory readiness program. Responsible for providing direction and oversight for regulatory and accreditation compliance including The Joint Commission (TJC), State and Federal agencies. Drives MSHS in maintaining preparedness for accreditation and licensure surveys.
**RESPONSIBILITIES**
In collaboration with Senior Director of Regulatory Affairs, and other system leadership, directs and facilitates a system-wide program to maintain continuous readiness for accreditation and regulatory surveys.
Leads the healthcare system in maintaining preparedness for accreditation and regulatory surveys.
Evaluates and recommends improvement to ensure adherence to relevant regulatory and accreditation standards.
Coordinates designated efforts to assure compliance with accreditation and regulatory requirements including gathering, synthesizing, and analyzing data from departments, and providing consultation to departments around compliance initiatives.
Supports and monitors the progress of corrective action plans/improvement projects and provides feedback on regulatory compliance.
Provides comprehensive reports to stakeholders, as appropriate, on accreditation and regulatory requirements.
Plays a lead role in regulatory and accreditation survey preparation, survey visit and post survey activities.
Implements educational presentations to facilitate continuous survey readiness and compliance with regulatory standards.
Serves as a subject matter expert and resource on accreditation and regulatory issues.
Maintains knowledge of standards, regulations, and reporting of requirements of The Joint Commission, Medicare Conditions of Participation, the New York State Department of Health, and other regulatory agencies.
Participates in professional activities and organizations to maintain knowledge of current trends, practices, and developments.
Other duties as assigned.
**QUALIFICATIONS**
Bachelors degree (Masters preferred).
RN licensure required.
5+ years (greater preferred) of experience in a clinical healthcare environment.
Experience in clinical operations and/or experience working in performance improvement, patient safety, risk management or quality management areas in the healthcare environment.
Knowledge of Quality Improvement methodology, group facilitation, project management, and healthcare regulatory event reporting requirements.
Previous accreditation/regulatory readiness experience preferred.
Non-Bargaining Unit, 621 - HSO Office of CMO - MSH, Mount Sinai Hospital
**REQUIRED SKILLS**
Microsoft Office Suite
**ABOUT US**
**Strength Through Diversity**
The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai's unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:
Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.
Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.
Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.
At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.
Explore more about this opportunity and how you can help us write a new chapter in our history!
**"About the Mount Sinai Health System:**
Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U. S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U. S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.
The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not d
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