Registered Nurse (Accreditation & Compliance Specialist)

1 day left

Location
Hampton, VA
Salary
Competitive
Posted
Jan 24, 2018
Closes
Feb 24, 2018
Specialty
Rehabilitation
Contract Type
Permanent
Hours
Full Time

Incumbent performs a variety of duties to include assessing, consulting, and strategy development to lead a health organization in accreditation; requires in-depth knowledge of The Joint Commission, Office of the Inspector General (OIG) and OIG Continuous Assessment Program (OIGCAP), Commission on the Accreditation of Rehabilitation Facilities (CARF), Long Term Care (LTC) and other accrediting/surveying bodies, as applicable.

  • Performs a variety of duties to include assessing, consulting, and strategy development to lead a health organization in accreditation; requires in-depth knowledge of The Joint Commission, Office of the Inspector General (OIG) and OIG Continuous Assessment Program (OIG-CAP), Commission on the Accreditation of Rehabilitation Facilities (CARF), Long Term Care (LTC) and other accrediting/surveying bodies, as applicable;
  • Develops and uses either an electronic or manual tracking system to ensure communication with respective owners, and that those individuals certify compliance with said documents;
  • Develops action plans, as necessary to address deficiencies to bring the organization into compliance;
  • Works with Service Chiefs/Program Managers to ensure local HVAMC Medical Center Memorandums (MCMs) and standard operating procedures (standard work) are aligned with accrediting and oversight body standards and on-site findings and/or accepted recommendations;
  • Prepares and/or coordinates statistical analysis, short- and long-range planning, work measurement techniques, qualitative analysis, program planning, and computer database management. Must have familiarity with the regulations and standards of regulatory and credentialing organizations that relate to hospital liability and standards of patient care;
  • Incorporates compliance and performance improvement activities within the overall program including controlling, directing, organizing, planning, and evaluating programs and outcomes; daily attention to the resolution of complex quality management problems; participation in executive-level decision-making deliberations, and performance in a full range of administrative duties. She/he maintains compliance with all patient privacy regulations;
  • Oversees the implementation of quality management functions and the interests of various employees and groups in the health care delivery system as the Accreditation and Compliance Specialist;
  • Conducts special assignments in relation to accreditation and policy compliance issues, the overall hospital mission, and/or items in VHA's best interest;
  • Compiles information and data, analyzes and summarizes findings, and develops and presents recommendations in report form;
  • Develops guidelines and new methods to address deficiencies and implement improvements.
Work Schedule: Monday through Friday, 8:00 a.m. to 4:30 p.m.
Financial Disclosure Report: Not Required
Recruitment/Relocation Incentives: Not Authorized
Relocation Expenses: Not Authorized
Virtual: This is not a virtual position
Telework: Not AuthorizedBasic Requirements:
  • United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
  • Graduate of a school of professional nursing approved by the appropriate State-accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing.
  • Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia.
  • BLS from American Heart Associate is a pre-employment requirement.
Preferred Experience: Three years clinical experience in an acute care setting. Two years of experience working in a quality service or accreditation support function in a health care setting. Two - five years experience in a healthcare regulatory related position is required. Three - five years progressive healthcare experience including accreditation compliance.

Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
  • Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required.
  • Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience.
  • Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience.
  • Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required.
  • Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree.
Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office.Physical Requirements: This position requires Heavy lifting(45 lbs and over); Moderate lifting(15-44 lbs); Light lifting(under 15 lbs); Light carrying(under 15 lbs); Pushing(2 hrs); Reaching above shoulder; Use of fingers; Both hands required; Walking(2-4 hrs); Standing(2-4 hrs); Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Far vision correctable in one eye to 20/20 and to 20/40 in the other; Both eyes required; Depth perception; Ability to distinguish basic colors; Ability to distinguish shades of colors; Hearing(aid permitted); Repetitive computer data entry; Emotional/mental stability; Occasional lift over 45 lbs for patient transfer; Sitting for over 1 hour; Visually able to use computer programs and spreadsheets.

Selected applicants will be required to complete an online onboarding process.

To apply for this position, you must provide a complete Application Package which includes:

  • Resume
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. Required at time of application.

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, etc.
  • Cover Letter
  • DD-214
  • 10-2850A
  • Other Veterans Document
  • Resume
  • SF-50
  • Transcript

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