GME Accreditation and Compliance Program Manager

Key Responsibilities

• ACGME Program Accreditation and Compliance – 40%
• Educate program directors and coordinators on their specialty-specific and institutional ACGME requirements.
• Organize and perform timely Midpoint Initial Accreditation Reviews and Mock Site Visits.
• Ensure that programs provide current information to ACGME within the regulatory guidelines and deadlines through a formal annual Accreditation Data System (ADS) Annual Update, and on an ongoing basis throughout the year, as required.
• Create additional dashboards by department.
• Develop and maintain expertise in continuously evolving regulatory requirements including ACGME Common, Specialty-specific Program Requirements and Institutional Requirements.

Institutional-Level ACGME Compliance

• Review & revise annually relevant GME policies and procedures impacting all GME programs, ensuring they are updated with any new regulatory requirements.
• Prepare institution for and participate in institutional-level site visits from ACGME.
• Organize, with the Associate Dean for GME, the monthly Graduate Medical Education Committee (GMEC) meetings, and monthly GMEC Subcommittee meetings and ensure that the content and membership satisfy ACGME requirements.
• Create GME templates using internal best practices and/or national outstanding models to assist the institution and the GME programs in meeting and exceeding compliance with ACGME standards.
• Write the Annual Institutional Report in collaboration with the Associate Dean for GME/DIO and prepare slides for DIO presentation of the Report.
• Submit annual institutional Accreditation Data System (ADS) update to ACGME.

Monitoring of Underperforming Programs

• Organize and participate in Special Reviews, as a member of the review team.
• Draft resulting reports and monitor program’s progress with corrective actions through required Progress Reports.
• Track Accreditation Citations and Areas for Improvement (AFIs), guiding programs through Progress Reports until they meet standards.

Non-ACGME-Accredited Program Oversight

• Partner with prospective new non-ACGME-accredited programs to complete extensive GMEC applications to establish new residencies and fellowships, in compliance with all requirements.
• Oversee, as part of three-member team, ongoing compliance with GME policy for ~112 non-accredited medical fellowship programs, including review of changes in program leadership, resident complement, and modifications to the original program description.
• For non-ACGME programs accredited by an external organization, oversee compliance to the extent required of the institutional DIO.
• Ensure compliance with additional ACGME NST requirements for ~25 programs with Non-Standard Training (NST) recognition.

Other Duties as Assigned

• Lead organization of semi-annual half-day GME Essentials orientation for new program directors and associate program directors.
• Perform a variety of special projects to support departmental, institutional, and ACGME initiatives, such as FTE data collection and assistance with GME Leadership Retreat planning and execution.
• Coordinate annual institutional Program Director and Program Coordinator Excellence Award process.
• Participate in GME long-range and short-term strategic planning.

Qualifications

• Bachelor’s degree in education, psychology, business, public administration, health care, educational technology, social science, liberal arts, communications, accounting, finance, library science, or a directly related field from an accredited institution and 4-6 years of professional experience in Graduate Medical Education (GME), academic medicine, healthcare administration, or a related field, including at least three (3) years supporting or managing ACGME-accredited residency and/or fellowship programs.
• Proven experience in leading and managing in a highly accountable work environment.
• An advanced degree (Masters or Doctorate) may be substituted for experience on a year for year basis if the degree is in a field of study directly related to the work assignment.

Conditions of Employment

• Applicants must be legally authorized to work in the United States without requiring sponsorship.
• We are unable to provide work visa sponsorship or employment authorization for this position now or in the future.