Accreditation and Regulatory Specialist

Discover Vanderbilt Health: With eight hospitals and over 180 clinics, we are the region’s largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you’ll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.

Organization:

Quality, Safety & Risk Prevent

Job Summary:

A detail-driven regulatory professional who ensures comprehensive organizational compliance by interpreting, implementing, and monitoring adherence to complex federal and state regulations. Collaborates across departments to identify compliance gaps, mitigate institutional risk, and support continuous quality improvement initiatives across the organization.

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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.

REQUIREMENTS

• Accreditation and Regulatory experience strongly prefered
• Nursing experience is preferred, but not required
• Some project management experience preferred

TECHNICAL CAPABILITIES
• 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.
• 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 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.
• 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.
• Project Management (Intermediate): Planning, organizing, and managing resources to bring about the successful completion of specific project goals and objectives.

About the Department:

The Department of Quality, Safety, and Risk Prevention (QSRP) equips and empowers Vanderbilt Health faculty and staff at our Main Campus, Regional Hospitals and Ambulatory Divisions to offer care that is safe, timely, effective, efficient and patient-centered. We are focused on providing high-quality care through doing the right thing for our patients to reach desired health outcomes, while also preventing errors or adverse events and reducing risks 

The various teams within QSRP foster knowledge sharing to extend best practice use, reduce variability and facilitate improvements in outcomes throughout our health system and strengthening Vanderbilt Health’s mission of personalizing the patient experience through our caring spirit and distinctive capabilities through our QSRP Strategic Plan.

Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.

At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.

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:- Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e 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:- 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: - 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: - 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:- 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.

Position Qualifications:

Responsibilities:

Certifications:

Work Experience:

Relevant Work Experience

Experience Level:

2 years

Education:

Bachelor's

This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth.

Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity.  EOE/Vets/Disabled.