Accreditation and Regulatory Specialist (Clarksville - Local / Hybrid)

Vanderbilt Health Job Opportunity

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.

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.

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. (Note: This role will be based at our Vanderbilt Clarksville Hospital, on-site full time for at least the first 6 months, hybrid possibly after that timeframe)

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 preferred

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.