Accreditation Regulatory Specialist (Local / Hybrid)

Discover Vanderbilt University Medical Center:  Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health is committed to an environment where everyone has the chance to thrive and where your uniqueness is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

Quality, Safety & Risk Prevention

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.

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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

• Nursing experience is preferred, but not required

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.

About the Department:

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