Accreditation Coordinator; RN

Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal.



Roles & Responsibilities: 


A member of the Mount Sinai Health System regulatory team, the Accreditation Specialist is a key participant in the system’s continuous accreditation and regulatory readiness program. Responsible for providing direction and oversight for regulatory and accreditation compliance including The Joint Commission (TJC), and State and Federal agencies. This individual assists in maintaining preparedness for accreditation and licensure surveys.


Duties and Responsibilities:

1.       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.

2.       Assists the healthcare system in maintaining preparedness for accreditation and regulatory surveys.

3.       Evaluates and recommends improvement to ensure adherence to relevant regulatory and accreditation standards.

4.       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.

5.       Supports and monitors the progress of corrective action plans/improvement projects and provides feedback on regulatory compliance.

6.       Provides comprehensive reports to stakeholders, as appropriate, on accreditation and regulatory requirements.

7.       Participates in regulatory and accreditation survey preparation, survey visit and post survey activities.

8.       Implements educational presentations to facilitate continuous survey readiness and compliance with regulatory standards.

9.       Serves as a resource on accreditation and regulatory issues.

10.     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.

11.     Participates in professional activities and organizations to maintain knowledge of current trends, practices, and developments.

12. Other duties as assigned.




Bachelors degree (Masters preferred), preferably in a health science.

RN licensure preferred.



5 years 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



1. RN


Strength Through Diversity


The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. 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 work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care. 


Explore more about this opportunity and how you can help us write a new chapter in our story! 


Who We Are


Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.


Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.


The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 


EOE Minorities/Women/Disabled/Veterans



EOE Minorities/Women/Disabled/Veterans

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