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Vanderbilt University Medical Center Accreditation Regulatory Specialist in Nashville, Tennessee

Accreditation Regulatory Specialist - 2107489

Job : Academic Support and Student Affairs

Primary Location : TN-Nashville-VMG Business Office - Blakemore

Organization : Quality A&S - Youngblood 108639

Shift: : First Shift

Description

Accreditation Regulatory Specialist

Quality, Safety and Risk Prevention

JOB SUMMARY:

Ensures organizational compliance with all applicable federal and state regulations under occasional guidance.

KEY RESPONSIBILITIES:

  • Uses proactive data analytics to identify potential regulatory risks.

  • Helps draft and implement corrective action plans along with unit leadership.

  • May initiate and advise on policy drafts and revisions.

  • Facilitates the review, response, and documentation of complaints received from external parties with occasional guidance.

  • Facilitates obtaining additional licensures, accreditations, and certification across the health systems.

  • May assist with regulatory visits.

  • The responsibilities listed are a general overview of the position and additional duties may be assigned.

Department Summary:

Quality, Safety and Risk Prevention (QSRP) equips and empowers VUMC faculty and staff to offer care that is safe, timely, effective, efficient, equitable and patient-centered.

The various teams within QSRP foster VUMC knowledge sharing to extend best practice use, reduce variability and facilitate improvements in outcomes. QSRP strengthens VUMC's mission to create best patient care through education, research and knowledge dissemination.

View how Vanderbilt Health employees celebrate the difference they make every day:

Discover Vanderbilt University Medical Center:

Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded and your abilities challenged. It is a place where your diversity — of culture, thinking, learning and leading — is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

VUMC Recent Accomplishments

Because we are committed to providing the best in patient care, education and research, we are proud of our recent accomplishments:

· US News & World Report: #1 Adult Hospital in Tennessee and metropolitan Nashville, named to the Best Hospitals Honor Roll of the top 20 adult hospitals, 10 nationally ranked adult specialty programs, with 3 specialties rated in the top 10 nationally, Monroe Carell Jr. Children’s Hospital at Vanderbilt named as one of the Best Children’s Hospital in the nation, with 10 out of 10 pediatric specialties nationally ranked.

· Healthcare’s Most Wired: Among the nation’s 100 “most-wired” hospitals and health systems for its efforts in innovative medical technology.

· Becker’s Hospital Review: named as one of the “100 Great Hospitals in America”, in the roster of 100 Hospitals and Health Systems with Great Oncology Programs and to its list of the 100 Hospitals with Great Heart Programs.

· The Leapfrog Group: One of only 10 children’s hospitals in the to be named at Leapfrog Top Hospital.

· American Association for the Advancement of Science: The School of Medicine has 112 elected fellows

· Magnet Recognition Program: Received our third consecutive Magnet designations.

· National Academy of Medicine: 22 members, elected by their peers in recognition of outstanding achievement

· Human Rights Campaign Healthcare Equality Index: 6 th year in a row that Vanderbilt University Medical Center was a Leader in LGBTQ Healthcare Equality.

TECHNICAL CAPABILITIES:

PROJECT MANAGEMENT (INTERMEDIATE): - Planning, organizing, and managing resources to bring about the successful completion of specific project goals and objectives.

REGULATORY COMPLIANCE (INTERMEDIATE): - Demonstrates knowledge of the appropriate rules and regulations and apply them in difficult, stressful and complex situations. Able to interpret and explain rules and regulations that are ambiguous or unclear. Directs others in interpreting rules and regulations on the job and trains others in them.

REGULATORY DOCUMENTATION (NOVICE): - Writes clear, concise and comprehensive documentation, such as computer program and systems specifications, product descriptions, operational procedures, etc. Incorporates accepted technical documentation conventions and uses graphics and other visual aids to assure understanding by the reader. Adheres to governmental documentation requirements and associated templates and forms. Creates outlines and organizes thoughts before attempting to write a document. Edits and proofreads drafts before completing documents, adopts constructive critiques and integrates changes easily.

REGULATORY STRATEGY (NOVICE): - Demonstrates ability to successfully prepare long-range plans for a major regulatory requirement. Demonstrates ability to forecast complex resource needs and recognize risks. Plans, budgets, and implements domestic and international regulatory strategies for new and modified products. Monitors prevailing and evolving international regulatory requirements. Merges diverse points of view into a coalition with shared goals and objectives. Identifies relevant stakeholders and gains their commitment.

HEALTHCARE DATA ANALYSIS (INTERMEDIATE): Navigates within established technology environments to locate, validate, extract, and format data for analysis. Able to modify and run queries and standard reports from data tools and provide to users. Can identify data values and data sources. Familiar with data modeling and able to interview business customers to elicit data requirements. Understands the relationships between data items.

CORE ACCOUNTABILITIES:

  • Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas related to own job area/team with occasional guidance.

  • Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment.

  • Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area.

  • Team Interaction: Provides informal guidance and support to team members.

CORE CAPABILITIES:

SUPPORTING COLLEAGUES (P2):

    • Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
    • Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
    • Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.

DELIVERING EXCELLENT SERVICES (P2):

    • Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
    • Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
    • Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.

ENSURING HIGH QUALITY (P2):

    • Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
    • Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
    • Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.

MANAGING RESOURCES EFFECTIVELY (P2):

    • Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
    • Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
    • Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.

FOSTERING INNOVATION (P2):

    • Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
    • Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
    • Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Basic Qualifications

Bachelor's Degree (or equivalent experience) and 2 years experience

  • Physical Requirements/Strengths needed & Physical Demands:

  • Sedentary category requiring exertion up to 10 lbs. of force occasionally and uses negligible amounts of force to move objects. Sedentary work involves sitting most of the time. Movement

  • Occasional: Standing: Remaining on one's feet without moving.

  • Occasional: Walking: Moving about on foot.

  • Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another

  • Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.

  • Occasional: Push/Pull: Exerting force to move objects away from or toward.

  • Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.

  • Frequent: Sitting: Remaining in seated position

  • Frequent: Reaching below shoulders: Extending arms in any direction below shoulders.

  • Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.

  • Frequent: Bimanual Dexterity: Requiring the use of both hands. Sensory

  • Continuous: Communication: Expressing or exchanging written/verbal/electronic information.

  • Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information

  • Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision

Req ID: 2107489

Vanderbilt University Medical Center is committed to principles of equal opportunity and affirmative action.

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