Nurse (Accreditation Program Manager)

Full Job Description

The Bronx VA Medical Center is recruiting for (1) full-time Registered Nurse Accreditation Program Manager reporting to the Quality and Patient Safety service at the James J. Peters facility.

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/12893721.

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.

*Note: Foreign education programs/degrees are not creditable as related degrees. Preferred Experience: 3 years as a hospital accreditation program manager and quality management specialist.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. Major Duties:

Duties include, but are not limited to: The Accreditation Program Manager (APM) Registered Nurse (RN) demonstrates leadership, experience, and creative approaches to improvement in quality-of-care outcomes.

The Accreditation Program Manager (APM) provides enterprise-level oversight of regulatory and accreditation compliance across the hospital and affiliated care sites.

The role operationalizes an "always survey-ready" model by translating external standards (e.g., Joint Commission, CMS Conditions of Participation, state regulations, specialty program requirements) into internal controls, workflows, and monitoring structures.

Core functions include maintaining the regulatory inventory, coordinating the triennial survey cycle, managing policy governance, and ensuring standards interpretation is consistently applied across clinical and non-clinical departments.

The APM serves as the authoritative resource for standards clarification, aligning leadership expectations with frontline practice and integrating requirements into daily operations rather than episodic preparation.

The APM designs and administers the continuous readiness infrastructure: tracer methodology, environmental rounding, document control processes, and compliance auditing programs.

This includes development of audit tools, risk-based audit schedules, deficiency tracking systems, and corrective action plans with defined owners, due dates, and sustainment verification.

The role facilitates interdisciplinary collaboration by working with service chiefs, nursing leadership, facilities, infection prevention, patient safety, and quality management to identify gaps, perform root cause analysis, and implement durable corrective actions.

The APM also prepares leaders and staff for surveyor interactions through education, mock surveys, just-in-time coaching, and leadership briefings, ensuring staff competency in articulating care processes and demonstrating compliance in real time.

From a governance perspective, the APM reports compliance status and risk posture to executive leadership and appropriate committees, escalating high-risk findings and monitoring mitigation effectiveness.

Responsibilities include coordinating responses to external reviews, managing evidence of standards compliance (ESC) submissions, validating closure of findings, and trending performance to prevent recurrence.

The scope extends beyond regulatory adherence to performance reliability, embedding accreditation requirements into quality improvement initiatives, performance dashboards, and strategic planning.

Through these activities, the APM ensures the organization not only meets regulatory expectations but sustains a culture of safety, accountability, and operational discipline that supports high reliability healthcare delivery.

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 8:30am to 5pm Compressed/Flexible: Not available Telework: Not available Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not authorized, Permanent Change of Station (PCS): Not authorized