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Primary Purpose:
Serves as the operational leader for accreditation readiness and continuous quality improvement (CQI) systems within the Dr. Kiran C. Patel College of Allopathic Medicine. In close collaboration with and under the strategic oversight of the Executive Associate Dean for Academic and Student Affairs (EADASA), this role designs, implements, and monitors a comprehensive, longitudinal accreditation and quality infrastructure that ensures sustained compliance with LCME standards and promotes a culture of continuous improvement. Operationalizes quality governance processes, maintains accreditation documentation systems, oversees policy life-cycle management, and monitors affiliation agreement compliance.
Job Category: Exempt
Hiring Range: Commensurate with experience
Pay Basis: Annually
Subject to Grant Funding? No
Essential Job Functions:
1. Leads the college’s ongoing compliance with LCME standards and other relevant accrediting bodies.
2. Maintains a structured, longitudinal accreditation readiness framework (dashboard, risk-tiering, monitoring cadence).
3. Oversees preparation of required reports (Annual questionnaires, status reports, self-study preparation, etc.).
4. Serves as primary liaison to the LCME Secretariat and other accrediting agencies.
5. Coordinates internal mock reviews and element-level monitoring cycles.
6. Aligns medical school accreditation processes with university-level accreditation (e.g., SACSCOC) where appropriate.
7. Designs and maintains a formal CQI governance structure, including, defining review cycles, element owners and accountability frameworks, risk-tier determination processes. and documentation standards.
8. Oversees development of data dashboards and visual analytics to support performance monitoring.
9. Ensures integration of student performance outcomes, faculty sufficiency metrics, learning environment data, and GQ and benchmarking data.
10. Facilitates CQI Taskforce and Committee-at-large operations.
11. Ensures CQI processes are longitudinal, documented, and evidence-based.
12. Develops and implements a comprehensive Policy Life-Cycle Protocol that includes standardized formatting and version control, legal and compliance review processes, scheduled review cadence (e.g., 3-year cycle), sunset and archival procedures, and policy impact assessments
13. Maintains a centralized, searchable policy repository (SharePoint or institutional system).
14. Ensures alignment between medical school policies and university policies.
15. Monitors adherence to approved policies across departments.
16. Develops a centralized tracking system for all affiliation agreements and educational MOUs.
17. Monitors agreement terms, expiration dates, renewal cycles, and compliance requirements.
18. Ensures agreements clearly define educational oversight responsibilities, faculty appointment structures, student supervision expectations, and compliance with LCME standards
19. Partners with Legal Affairs and Clinical Affairs to review and update agreements as required.
20. Conducts periodic audits to ensure operational compliance at affiliated sites.
21. Coordinates the accurate and timely annual revision of the College’s section of the University Catalog.
22. Ensures alignment between catalog language, LCME standards, and operational practice.
23. Coordinates with Student Affairs leadership to prompt and track annual revisions of the Student Handbook.
24. Conducts crosswalk reviews to ensure consistency between catalog, Student Handbook, Faculty Handbook, Committee policies, and LCME documentation.
25. Maintains version control and archival records of all published materials.
26. Works with academic, corporate and other partners to advance the educational, research and health-related missions of the College.
27. Assists with developing the College's Faculty Practice Plan and the policies and procedures in support thereof.
28. Assists in the development/implementation of policies and procedures to support the management of business, physician and patient relationships including matters related to physician practice, patient communications and discharge, billing (federal, state, and private), operation of state-supported Child Protection Teams and similar programs providing services to patients/clients.
29. Directs the development of College policies, procedures and oversees implementation.
30. Participates on the Quality Improvement Committee (education) and Faculty Development Program for the College.
31. Works collaboratively to create policies and a regulatory environment for the College's Practice Plan.
32. Works collaboratively to address LCME accreditation, student academic problems and issues related to the College's academic programs.
33. Serves on academic or administrative committees that deal with institutional policies, departmental matters, and academic issues.
34. Completes special projects as assigned.
35. Performs other duties as assigned or required.
Job Requirements:
Required Knowledge, Skills, & Abilities: Knowledge:
1. Administration and Management - Advanced knowledge of business and management principles involved in strategic planning, resource allocation, budgeting, human resources modeling, leadership technique, and/or coordination of people and resources.
2. Customer and Personal Service - Thorough knowledge of principles and processes for providing customer and personal services. This includes needs assessment, meeting quality standards for services, and evaluation of user satisfaction.
3. English Language - Thorough knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
4. Education and Training - Thorough knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects.
Skills:
1. Critical Thinking - Advanced skills in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
2. Reading Comprehension - Advanced understanding of written sentences and paragraphs in work-related documents.
3. Speaking - Advanced skills in talking to others to convey information effectively.
4. Judgment and Decision Making - Advanced skills in considering the relative costs and benefits of potential actions to choose the appropriate one.
5. Writing - Advanced skills in communicating effectively in writing as appropriate for the needs of the audience.
6. Complex Problem Solving - Advanced skills in identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
7. Active Listening - Advanced skills in giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Abilities:
1. Problem Sensitivity - The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
2. Inductive Reasoning - The ability to combine pieces of information to form general rules or conclusions (including finding a relationship among seemingly unrelated events).
3. Deductive Reasoning - The ability to apply general rules to specific problems to produce answers that make sense.
4. Fluency of Ideas - The ability to come up with a number of ideas about a topic (the number of ideas is important, not their quality, correctness, or creativity).
Physical Requirements:
1. Speech Recognition - Must be able to identify and understand the speech of another person.
2. Speech Clarity - Must be able to speak clearly so others can understand you.
3. Near Vision - Must be able to see details at close range (within a few feet of the observer).
4. May be required to work nights or weekends.
5. Travel - Must be able to travel on a daily and/or overnight basis.
6. May be exposed to short, intermittent, and/or prolonged periods of sitting and/or standing in performance of job duties.
7. May be required to accomplish job duties using various types of equipment/supplies, to include but not limited to pens, pencils, and computer keyboards.
Required Certifications/Licensures:
Required Education: Master's Degree
Major (if required:
Required Experience: Ten (10) or more years of experience in higher education administration.
Preferred Qualifications:
Medical school experience preferred.
Is this a safety sensitive position? No
Background Screening Required? No
Pre-Employment Conditions:
Sensitivity Disclaimer: Nova Southeastern University is in full compliance with the Americans with Disabilities Act (ADA) and does not discriminate with regard to applicants or employees with disabilities and will make reasonable accommodation when necessary.
NSU is an Equal Opportunity Employer and considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status or any other legally protected status.
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