Accreditation and Certification Services Director

Mount Sinai Medical Center - Florida - Miami Beach, FL 33140 (Nautilus area)
Estimated $69.1K - $87.4K a yearFull-time

Accrediation and Certification Services Director
As Mount Sinai grows, so does our legacy of caring

Located in the heart of Miami Beach, overlooking the breathtaking intracoastal waterway, Mount Sinai Medical Center is dedicated to providing exceptional health care to our diverse community enhanced through innovation, technology, teaching, and research.

Mount Sinai is South Florida's largest private independent not-for-profit hospital with 672 beds, and a tight-knit community of more than 4,000 employees.

We provide world-class care:

  • Named one of America's 250 Best Hospitals for 2020 and 2021 by Healthgrades, positioning Mount Sinai among the top 5% of hospitals in the nation for overall clinical excellence.
  • A pioneer in innovative medical research in areas such as cardiology, cancer, memory disorders and pulmonary diseases
  • The BEST cardiac surgery survival rate in Florida
  • A new seven-story Surgical Tower with 154 all-private rooms and patient centered technology promotes an exceptional patient experience

Position Responsibilities:

  • Manages a Hospital-wide Quality Management and Performance Improvement program consistent with the facilities strategic plan.
  • Manages hospital compliance with the JCAHO standards, Conditions of Participation and other regulatory standards pertaining to Quality.
  • Conducts overall facility annual evaluation during the first quarter.
  • Provides direction to facility leadership as necessary in connection with quality management, performance improvement and accreditation readiness.
  • Organizes teams for conducting root cause analysis and other performance improvement teams. Follows up on all recommended actions and submits timely reports to MSQP & Patient Safety Committee as necessary and required.
  • Coordinates implementation of Plan of Correction based upon Accreditation and Survey reviews.
  • Provides trend reports to appropriate personnel and other committees.
  • Collaborates with other members of the Quality Management Department to identify hospital systems in need of improvement.
  • Notifies immediate supervisor of all sensitive situations as soon as possible.
  • Prepares quarterly reports for presentation to Board regarding hospital-wide quality efforts, patient safety and accreditation visits.
  • Helps to ensure compliance with regulatory requirements, professional standards and guidelines.
  • Demonstrates skill in planning, organization, and implementation of work assignments or projects.
  • Conducts special projects at the direction of immediate supervisor.
  • Assures the hospital's compliance with all federal, state and local regulations regarding accreditation and quality.
  • Assists in keeping medical staff, administration and department managers updated on new regulatory developments.
  • Provides appropriate facility staff and administration representatives with changes in regulatory and statutory requirements affecting the facility.
  • Accompanies state and federal surveyors during scheduled and unannounced regulatory surveys.
  • Provides reports as requested to state and/or federal regulatory entities.
  • Ensures education to all new employees upon employment of the Quality and Performance Improvement Program.
  • Plans, coordinates and provides for inservice education related to Quality, accreditation and performance improvement for all hospital personnel in accordance with identified needs and State guidelines.
  • Participates on appropriate hospital committees to ensure collaborative efforts in monitoring and evaluation of identified quality issues and assists in problem resolution.
  • Maintains quality data relating to the hospital's performance.
  • Responsible for maintaining and preparing the annual and monthly agenda and meeting notices for MSQP.
  • Participates in developing a hospital-wide Quality Plan consistent with the facilities strategic plan, national quality initiatives and regulatory compliance.
  • Maintains confidentiality of all peer reviews, quality management and other sensitive materials.
  • Participates in ensuring that the Medical Staff Quality Performance Committee (MSQP) meets regulatory standards, reviews relevant quality issues and meets regularly to meet the needs of the hospital and comply with the medical staff bylaws.
  • Stays up to date on JCAHO, National Quality Initiatives and other regulatory agency standards.
  • Administers and manages teams, committees and other processes to comply with regulatory standards.
  • Ensures that a process is in place to prepare for and manage scheduled accreditation surveys.
  • Ensures a process is in place to manage unannounced accreditation surveys. Deals with surveyors in a professional manner and responds to written plans for corrective action.
  • Ensures a plan is in place to monitor on-going compliance with regulatory standards. Reports findings as required at appropriate committees.
  • Ensures performance improvement teams are in place when needed to solve quality issues. Ensures the teams document the issues, put effective action plans in place and turn in reports for on-going measurement of continued improvement.
  • Ensures root-cause analyses are conducted for any incident meeting criteria for sentinel event as defined by the JCAHO. Develops a plan to ensure monitoring of a written corrective action plan and that the action plan was effective.
  • Stays up to date on the National Patient Safety Goals. Makes recommendations for implementation and on-going monitoring.
  • Writes reports for the Patient Safety Committee.


  • CPHQ Preferred
  • Four year college degree in HIM, Nursing or other healthcare field
  • At least four years experience in preparing for a JCAHO survey


We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs. Our robust employee benefits package includes:

  • Health benefits
  • Life insurance
  • Long-term disability coverage
  • Healthcare spending accounts
  • Retirement plan
  • Paid time off
  • Tuition reimbursement
  • Employee assistance program
  • Wellness program
  • On-site housing for selected positions and more!

Attention - In the recruitment process, legitimate companies never withdraw fees from candidates. If there are companies that attract interview fees, tests, ticket reservations, etc. it is better to avoid it because there are indications of fraud. If you see something suspicious please contact us: [email protected]
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