Mount Sinai Careers

Accreditation Specialist, RN

New York, New York
Professional / Managerial / Administrative

Job Description

The Mount Sinai Health System


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The Mount Sinai Health System’s commitment to excellence extends beyond delivering world-class health care. The System’s ongoing success is dependent upon our highly motivated, nonclinical professionals working to improve business operations. Our leadership team is driven to provide exceptional service by cultivating a workforce that is dedicated to upholding Mount Sinai’s mission of delivering innovative, breakthrough medicine with compassion and integrity.


Are you ready to discover the world of limitless possibilities that comes with wearing the badge? Explore more about this opportunity and how you can help us write a new chapter in our story of unrivaled patient care!



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 preferred (NYS)



Do you share our dedication to extraordinary service and have what it takes to wear the badge? Apply now!



Who We Are:


Over 35,000 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 Roosevelt, Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.


The Mount Sinai Health System is committed to the tenets of diversity and workforce that are strengthened by the inclusion of and respect for our differences. We offer our employees a highly competitive compensation and benefits package, a 403(b) retirement plan, and much more.


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


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