Director; Quality Cardiac Services; Mount Sinai Heart Hospital; Full Time; Days

The Director of Regulatory Readiness of The Mount Sinai Hospital reports directly to the Vice President of Quality and Regulatory Affairs. This position collaborates with leadership and staff to support the mission of The Mount Sinai Health System/ Mount Sinai Heart with seamless coordination.

Regulatory responsibilities are inclusive and comprised of Joint Commission, CMS, NYSDOH survey and/other activities incorporating ongoing readiness and assurances of compliance with any regulatory body or related activity. These activities include but are not limited to:  Article 28, Joint Commission accreditation, certification and complaint investigation, onsite reviews, review preparation, follow-up actions, measures of success and accountability for timely responses.

• Function as administrative liaison to departmental and clinical leadership pertaining to all matters of regulatory compliance at the Mount Sinai Hospital
• Facilitate the implementation of a constant state of Joint Commission, CMS and DOH readiness and awareness and institute programs that promote ongoing education, mock surveys, clinical and system tracers 
• Oversee the implementation and auditing of clinical department FPPE and OPPE 
• Oversee responses to all NYSDOH, and CMS Statements of Deficiencies and Joint Commission Evidence of Standards Compliance and complaint investigations to ensure timeliness and accuracy   
• Develop and maintain Administrative policies and procedures
• Develop regulatory strategies and implementation plans
• Oversee emerging healthcare trends and regulations to determine potential impact on practice 
• Oversee documentation efforts to ensure compliance with hospital, system, State and Federal guidelines
• Assist the Senior Director with the implementation of outreach initiatives designed to fully engage clinical departments and their chairmen as well as key core department leaders 
• Monitor the implementation and compliance with new and existing State and Federal regulations 
• Ensure streamlined processes are in place for valid and reliable data transmission to CMS, The Joint Commission, other regulatory agencies and managed care providers 
• Administrative liaison support for the NYSDOH  Health Commerce System   
• Function as Mount Sinai Quality Net Administrative Public Reporting back up liaison  
• Assist the Senior Director with the recruitment, selection, orientation, retention, mentoring, and evaluation of QA staff members
• Other responsibilities as assigned

 

• Masters degree in Nursing, Business Administration, Public Health or other health related field required. 
• Certified in Quality and or Six Sigma Green Belt and or LEAN Training preferred   
• 3-5 years progressive experience in Quality/Performance Improvement, supervision and team management  
• Experience Supporting a Cardiac Service line preferred

 

Non-Bargaining Unit, 535 - Quality Assurance - MSH, Mount Sinai Hospital

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.

We work hard to acquire and retain the best people and to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to professional advance. We share the belief that all employees, regardless of job title or expertise contribute to the patient experience and quality of patient care.

 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, e