What are the responsibilities and job description for the Registered Nurse, Nursing Regulatory & Accreditation Coordinator position at VA Central Texas Health Care System?
The Nursing Regulatory and Accreditation Coordinator is the primary contact for nursing regulatory surveillance, accreditation readiness, and external review activities across the Central Texas Veterans Health Care System. This role ensures ongoing compliance with accreditation standards and Veterans Health Administration directives by providing expert oversight, conducting assessments, and coordinating corrective actions.
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/12940958.
*Note: Foreign education programs/degrees are not creditable as related degrees.
Preferred Experience:
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Physical Requirements:
This position may require potentially long periods of continued Heavy lifting of 45 pounds and over, Moderate lifting of 15-44 pounds, Heavy carrying of 45 pounds and over, Moderate carrying of 15-44 pounds, Light carrying under 15 pounds, Straight pulling for 1-2 hours, Pushing for 1 hour, Reaching above shoulder, Use of fingers, Walking for 8-10 hours, Standing for 8-10 hours, Repeated bending .5 hours, Both legs required, 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 may be permitted) Mental and emotional stability, Simple grasping for 2-4 hours, Sitting for 8 hours, Fine manipulation for 4-8 hours, Twisting for 2 hours.
The Nursing Regulatory & Accreditation Coordinator Registered Nurse (RN) duties include but are not limited to providing expert oversight, consultation, and coordination to ensure nursing services maintain continuous compliance with accreditation standards, Veterans Health Administration directives, local policies, and professional practice guidelines. The incumbent plays a critical role in supporting the organization's readiness for accrediting and monitoring bodies. The incumbent coordinates responses to regulatory findings related to nursing practice, supports development of corrective action plans, and monitors the implementation and sustainability of corrective actions to ensure ongoing compliance. The incumbent is assigned responsibility for activities within their designated scope across the entire medical center and applicable off-site locations.
The RN Regulatory & Accreditation Coordinator plans, organizes, and implements facility-wide assessments of nursing practice to evaluate survey readiness and regulatory compliance within both clinical and non-clinical settings. Responsibilities include organizing and conducting regular tracers, targeted reviews, and evaluations of nursing practice and care delivery processes to ensure alignment with regulatory standards, VHA requirements, and local policy. The incumbent actively identifies potential organizational or departmental vulnerabilities by engaging with frontline staff, managers, and interdisciplinary leaders, and works collaboratively with operational partners to establish internal controls, implement corrective strategies, and measure outcomes. Findings from tracers and assessments are aggregated, analyzed, and communicated through appropriate governance structures to inform leadership decision-making and system improvement.
The RN serves as a subject matter expert (SME) and interprets and applies accreditation standards and VHA regulatory requirements impacting nursing services to guide nursing leaders in achieving and sustaining compliance. The incumbent advises staff on interpretation of regulatory standards, evaluates situations for compliance with accreditation and regulatory requirements, and provides consultation to support corrective action development and regulatory risk mitigation. The incumbent partners with nurse leaders to monitor previously completed corrective actions to evaluate sustained compliance and ensure that regulatory recommendations are tracked to completion.
The RN leads and facilitates nursing improvement initiatives and collaborates with organizational partners to integrate accreditation readiness with other quality and safety programs, including peer review, patient safety, ongoing professional practice evaluation, and systems redesign initiatives. Using systematic, data-driven improvement methodologies, the incumbent promotes strong leadership practices, patient safety, high reliability, and continuous performance improvement throughout the organization. The incumbent identifies and disseminates best practices and collaborates with operational leaders to ensure improvements are sustained across programs and services.
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: Monday - Friday, 7:00am - 3:30pm or 7:30am - 4:00pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
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.)
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/12940958.
| 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. |
Preferred Experience:
- Evidence of Belt/Systems Redesign training/experience/certification.
- SNT/GNT/RNTTP completion <5 years.
- Professional Governance participation.
- Preceptor/charge nurse experience/training (combination of experience and training is acceptable).
- Evidence-Based Practice experience/training (combination of experience and training is acceptable).
- >2 years regulatory surveillance, accreditation readiness, and/or quality improvement.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Physical Requirements:
This position may require potentially long periods of continued Heavy lifting of 45 pounds and over, Moderate lifting of 15-44 pounds, Heavy carrying of 45 pounds and over, Moderate carrying of 15-44 pounds, Light carrying under 15 pounds, Straight pulling for 1-2 hours, Pushing for 1 hour, Reaching above shoulder, Use of fingers, Walking for 8-10 hours, Standing for 8-10 hours, Repeated bending .5 hours, Both legs required, 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 may be permitted) Mental and emotional stability, Simple grasping for 2-4 hours, Sitting for 8 hours, Fine manipulation for 4-8 hours, Twisting for 2 hours.
Responsibilities:
CTVHCS is in the process of making a cultural change, shifting from a disease-focused approach to a health and wellbeing approach, in order to implement the Whole Health System of Care. This is a VA-wide initiative to provide a comprehensive and systematic approach to improve healthcare delivery at all stages of Veteran care. This entails moving from an episodic, "siloed" approach to an interdisciplinary, holistic approach, emphasizing self-care in the larger context of well-being. All staff in this facility will be part of this process, shifting the focus from the question, "What's the matter with you?" to the question, "What matters to you, and how can we help you live your best life?" This strategy also involves integrating a full range of conventional approaches with Complementary and Integrative Health (CIH) approaches in order to optimize lifelong health and well-being, as defined by the Veteran, rather than narrowly focusing on disease management.The Nursing Regulatory & Accreditation Coordinator Registered Nurse (RN) duties include but are not limited to providing expert oversight, consultation, and coordination to ensure nursing services maintain continuous compliance with accreditation standards, Veterans Health Administration directives, local policies, and professional practice guidelines. The incumbent plays a critical role in supporting the organization's readiness for accrediting and monitoring bodies. The incumbent coordinates responses to regulatory findings related to nursing practice, supports development of corrective action plans, and monitors the implementation and sustainability of corrective actions to ensure ongoing compliance. The incumbent is assigned responsibility for activities within their designated scope across the entire medical center and applicable off-site locations.
The RN Regulatory & Accreditation Coordinator plans, organizes, and implements facility-wide assessments of nursing practice to evaluate survey readiness and regulatory compliance within both clinical and non-clinical settings. Responsibilities include organizing and conducting regular tracers, targeted reviews, and evaluations of nursing practice and care delivery processes to ensure alignment with regulatory standards, VHA requirements, and local policy. The incumbent actively identifies potential organizational or departmental vulnerabilities by engaging with frontline staff, managers, and interdisciplinary leaders, and works collaboratively with operational partners to establish internal controls, implement corrective strategies, and measure outcomes. Findings from tracers and assessments are aggregated, analyzed, and communicated through appropriate governance structures to inform leadership decision-making and system improvement.
The RN serves as a subject matter expert (SME) and interprets and applies accreditation standards and VHA regulatory requirements impacting nursing services to guide nursing leaders in achieving and sustaining compliance. The incumbent advises staff on interpretation of regulatory standards, evaluates situations for compliance with accreditation and regulatory requirements, and provides consultation to support corrective action development and regulatory risk mitigation. The incumbent partners with nurse leaders to monitor previously completed corrective actions to evaluate sustained compliance and ensure that regulatory recommendations are tracked to completion.
The RN leads and facilitates nursing improvement initiatives and collaborates with organizational partners to integrate accreditation readiness with other quality and safety programs, including peer review, patient safety, ongoing professional practice evaluation, and systems redesign initiatives. Using systematic, data-driven improvement methodologies, the incumbent promotes strong leadership practices, patient safety, high reliability, and continuous performance improvement throughout the organization. The incumbent identifies and disseminates best practices and collaborates with operational leaders to ensure improvements are sustained across programs and services.
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: Monday - Friday, 7:00am - 3:30pm or 7:30am - 4:00pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Salary : $79,295