Graduate Medical Education Accreditation Specialist

Job Description

What Makes Us Different?

At FMOL Health, we offer you so much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital, we are here to create a spirit of healing. We offer you something special - the chance to do God's work by helping to serve people in need throughout our community, every day.

Job Summary

The GME Accreditation Specialist is responsible for maintaining oversight of the accreditation process for each individual specialty program as well as institutional accreditation for accredited hospitals within our entire health system. This role involves coordinating accreditation processes, maintaining documentation, and supporting program directors and residents to achieve and maintain accreditation status. Additionally, the specialist will oversee the clinical learning environment for the institutions. The GME Accreditation Specialist will also hold responsibilities in the academic affairs department to ensure compliance with accreditation standards.

Minimum Requirements

Experience - 5 years of work experience in a healthcare or academic setting.

Education - Bachelor's Degree required in Education, Healthcare or Business Administration, Nursing, Allied Health, or related field.

Apply now! Here, you are more than an employee. You are a team member, a co-worker, our friend and part of our family. Our healthcare team is working together to heal this community one patient at a time!

Responsibilities

• Accreditation
• Develop and assist in the implementation of standardized processes for the accreditation process for the institution, residency, and fellowship programs across the System.
• Monitor and ensure all system residency and fellowship programs meet relevant accreditation standards, including ACGME, to maintain the quality of our educational programs.
• Serve as a central point of contact for all regulatory and accreditation matters, providing clear and consistent guidance to hospitals within our system.
• Share regulatory and accreditation requirements with hospitals, ensuring they are well-informed and prepared for accreditation reviews and audits.
• Ensure compliance with ACGME, Joint Commission, and other relevant accrediting bodies.
• Coordinate accreditation activities including ACGME Site Visits.
• Facilitate ongoing readiness and continuous improvement of the institutional learning environment, ensuring it meets the highest standards of educational excellence for the ACGME Annual Institutional Review (AIR).
• Assist the Designated Institutional Officer in all correspondence with ACGME at the institutional and program levels including the Annual Institutional Review (AIR) and the Annual Program Evaluation (APE).
• Track residency program citations and program action plans to address ACGME citations.
• Develop and implement strategies for continuous improvement in GME programs.
• Clinical Learning Environment
• Focus on continuous improvement and management of the institutional and clinical learning environments, ensuring they meet the highest standards of educational excellence and accreditation requirements.
• Monitor and ensure ACGME Annual Resident, Fellow, and Faculty Surveys are completed by the annual deadline.
• Collect and review all surveys, including the Institutional Survey.
• Update policies and delineation of privileges.
• Assist with the creation and oversight of departmental affiliation agreements. Ensure that all agreements align with the organization’s goals and regulatory requirements and prioritize partnerships with quality institutions to strengthen the workforce pipeline.
• Ensure appropriate and frequent communication between affiliated institutions, residency programs, and Academic Affairs, supporting the Director of Academic Affairs and Designated Institutional Officer.
• Documentation and Reporting
• Maintain accurate and up-to-date records of accreditation-related documentation.
• Manage and maintain all ACGME-related files.
• Develop and ensure the policies from each sponsored program are maintained, updated, reviewed, and approved by Legal.
• Review each sponsored program’s Annual Program Evaluations and collaborate with the DIO and program coordinator on action items.
• Create executive summary of Annual Institutional Report (AIR) and assist with yearly update to the board.
• Be proficient in using New Innovations and pull reports as necessary
• Verify accurate GME Resident and Fellow personnel online records and credentialing documentation which must be accurate, present, and in order to ensure continued accreditation.
• Facilitate the creation of new programs through the application building process, including serving as the initial program support during the application and accreditation phase.
• Ensure all action plans documented related to duty hours are transparent to all involved to eliminate the risk of further violations.
• Serve as a key resource for organizing and analyzing departmental data to identify trends, monitor compliance, and support data-driven decision-making.
• Support and Training
• Provide guidance and training to program directors, coordinators, residents, and fellows on accreditation standards and requirements.
• Collaborate with Director, Academic Affairs to ensure program coordinators are given proper initial and continued training.
• Assist program coordinators with processing house staff travel, including review and processing of resident requests for conference travel and handling of reimbursements.
• Develop and maintain positive and supportive relationships with the OLOL GME Programs and affiliated GME programs.
• Assist with special projects and duties as assigned by the Director of Academic Affairs and the Designated Institutional Officer.
• Coordinate all GMEC Executive, subcommittee meetings, and special called meetings, including notices, location, food arrangements, attendance tracking, and detailed minutes.
• Be aware of onboarding, credentialing, and employment file processes for new incoming Residents and Fellows and communicate any changes in regulation requirements to the onboarding team.
• Manage and ensure successful completion of all current Resident and Fellow advancement and distribution, and collection of renewing annual Resident and Fellow Contracts.
  
  

Qualifications

Minimum Required Education: Bachelor's Degree required in Education, Healthcare or Business Administration, Nursing, Allied Health, or related field.

Minimum Experience: 5 years of work experience in a healthcare or academic setting.