Registered Nurse - Accreditation Coordinator

Veterans Health Administration, Department of Veterans Affairs; New Orleans (LA); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Paid Time Off: 26 days annual leave +

Sick leave 13 days

Job summary

The Accreditation Coordinator RN position within the Quality Management Service at the Veterans Health Administration requires leadership in accreditation readiness, coordinating activities with affected units, and acting as the technical advisor on accreditation standards. The role emphasizes preparation for surveys, issue briefs, and action items across facilities.

Preferred qualifications include an RN license in good standing and experience with accreditation programs, along with strong

Qualifications

• English language proficiency required by policy
• Current, full, active, and unrestricted RN license in a US state or territory
• Foreign nursing education may require degree equivalency validation
• State licensure is required for appointment in nursing roles

Responsibilities

• Coordinate accreditation activities across the Southeast Louisiana Veterans Health Care System
• Serve as technical advisor on accreditation matters and continuous readiness
• Lead and participate in accreditation surveys, preparation, and response actions
• Develop and coordinate internal review systems including tracers, audits, and mock surveys

Skills

English language proficiency

Interpersonal skills

Critical thinking

Education

RN license (US)

Job description

Summary

The Registered Nurse {RN) who serves as the Accreditation Coordinator in the Quality Management Service. He/she is designated a technical advisor in all matters pertaining to accreditation and continuous readiness and coordinates all accreditation activities with affected individuals/services {e.g. - presurvey/post survey requirements - associated Issue Briefs - Action Items}.

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/13105630
• 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 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
• Inter personal 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/.

Duties

• The Accreditation Coordinator focus is on individual growth and development in practice with increased levels of self-direction and limited critical thinking skills
• Provides expertise and leadership in the areas of the facilities OIG healthcare inspections and related inquiries - TJC standards - Office of Accountability and Whistleblower Protection (OAWP) - the Office of the Medical Investigator (OMI) - CARF - LTC - Ascellon - and other internal and external survey programs
• Responsible for implementing and maintaining accreditation activities across the Southeast Louisiana Veterans Health Care System (SLVHCS)
• The Accreditation Coordinator has the responsibility for planning and coordinating continual regulatory compliance readiness activities throughout the Medical Center and Community Based Outpatient Clinics (CBOCs)
• Adheres to established policies - standards of care - and regulations
• Develops and participates in all aspects of Quality Improvement (QI) projects and implements QI when possible
• Utilizes a team approach when interacting with multidisciplinary teams and affiliates - and provides consultation to other units on individual patients and provides in-services for OIG and Regulatory related activities
• The Accreditation Coordinator serves on - or leads - committees - workgroups - and teams as assigned by management
• exercises control and continuing responsibility for projects - questions - or problems associated with the various compliance programs across the medical center
• The incumbent plays a critical support role in developing and coordinating internal review systems including tracers - audits - and mock surveys - to assure that both clinical and administrative programs are in compliance with agency - accrediting standards - and regulatory requirements
• Collaborates with leadership - unit managers - and frontline employees to identify accreditation related educational training needs for staff - while supporting activities that foster competence - critical thinking skills - and decision making
• Acts as a resource across departments/services-providing assistance and training as needed to both clinical and nonclinical staff
• Attends interdisciplinary meetings daily and attend any staff - national or VISN meetings assigned
• 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 08:00am - 04:30pm - Subject to changed based on the facility needs
• Telework: AD-Hoc only Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized