Registered Nurse - Accreditation Manager

Summary

The Accreditation Manager is a professional nurse who functions as a coordinator and point of contact for external accreditation and other review activities for the Fayetteville North Carolina Coastal Health Care Center. The incumbent is a key person to help build and implement external accreditation/review systems and promote the culture of understanding the required standards and facilitate compliance in all healthcare settings.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate 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)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• 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
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12917031
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Preferred Experience: Experience with preparation - coordination - and knowledge of a variety of accreditation organizations and programs
• Experience with a wide range of specialized management analysis tools and techniques and applying these skills on difficult and complex work assignments
• Skill in preparing project papers and staff reports and in organizing and delivering briefings to managers to encourage understanding and acceptance of findings and recommendations
• Interpersonal skills in presenting recommendations and negotiating solutions to disputed recommendations
• Experience with pertinent laws - regulations - policies - and precedents which affect the use of administrative and related support resources in the area studied
• Experience in major issues - program goals and objectives - and work processes of the organization
• Ability to work well with others and across divisions Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: This position requires visual acuity - keen hearing - clear distinctive speech - and manual dexterity
• The position requires potentially long periods of combined walking - standing - stooping - sitting - bending - pulling - and pushing
• The incumbent must be a mature - flexible - sensible individual capable or working effectively in stressful situation - able to shift priorities based on needs of the organization
• The incumbent who provides off-site training may be required to travel occasionally
  
  

Duties

• Duties include but are not limited to: The Accreditation Manager is assigned responsibility for the accreditation management program area activities for the Medical Center and all off-site locations
• The incumbent has primary responsibility for training and implementation of the standards applicable to each external accreditation/review (i.e. - TJC - CARF - OIG etc.) process to clinicians - management - and all relevant support personnel within facility
• The incumbent collects data - monitors staff compliance with relevant policies - directives - and standards - provides reports detailing trends - and provides direct staff support to all services in planning - designing - integrating - implementing - modifying - and administering - a comprehensive accreditation management program area
• Provides direct support to the development - maintenance - and operation of the external accreditation/review program at the facility level
• This includes working with all levels of staff within the facility - including executive-level management
• The incumbent also works with and assists external accreditation/review activities of similar personnel within the facility - such as the nursing and medicine clinical evaluators
• The incumbent is responsible for translating standards - policies - directives - theories - and strategies into action within the complex interrelationships that exist related to external accreditation/review
• .Executes the position responsibilities that demonstrate effective leadership - detailed planning - professional communication - creative and innovative approaches to the improvement of safety/healthcare program development and possess an ability to organize priorities
• The Accreditation Manager performs duties directly contributing to high quality and safe patient care within the Veterans Health Administration (VHA) VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary - regular salary increases - potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: 8:00am - 4:30pm - Monday - Friday Telework: Ad-hoc Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized