Registered Nurse- Quality Management Accreditation Specialist

Full Job Description

The Battle Creek VA Medical Center is recruiting for a Registered Nurse in the Quality Resource Service. 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/12882871.

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.

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

Physical Requirements: Heavy Lifting 50 lbs and over (intermittently); Carrying up to 45 lbs (intermittently); Repeated bending; Straight Pulling up to 45 lbs (intermittently); Straight Pushing up to 45 lbs (intermittently); Stooping (intermittently); Squatting (intermittently); Kneeling (occasionally); Use of both arms; Use of both hands; Use of fingers; Overhead work, both arms (intermittently); Prolonged walking (up to 4 hours/day); Prolonged standing (up to 4 hours/day); Sitting (up to 2 hours/day); Far Vision - correctable in one eye to 20/20 and 20/40 in the other; Near Vision - correctable to read newsprint at 13-16 inches; Ability to distinguish shades of colors; Hearing - ability to hear and understand the spoken voice from a distance of 8 feet.

Ability to effectively utilize a stethoscope and distinguish breath and heart, and bowel sounds; Emotional and mental stability - ability to effectively perform the essential functions of the position and respond appropriately in emergency situations.

Major Duties:

The Quality Management Accreditation Specialist is a registered professional nurse, qualified by education and experience to monitor and evaluate clinical and administrative processes for the delivery of patient care throughout the Medical Center.

This role functions independently and frequently interacts with Medical Center leadership, including service chiefs, product line managers, middle managers, and staff.

The incumbent also collaborates with external accrediting bodies, community healthcare entities, veteran service organizations, and VHA employees at the Network and national levels.

This position executes responsibilities that demonstrate leadership, experience, and innovative approaches to managing complex clinical and administrative healthcare issues.

Primary duties include: Leadership and Management of the Continuous Survey Readiness Program, ensuring compliance with federal regulatory requirements, internal survey processes, and external accreditation standards.

Developing and implementing proactive, systematic approaches to accreditation readiness, ensuring standards are reviewed, processes updated, and staff educated in a timely manner.

Serving as liaison with accreditation organizations, coordinating document submissions to accrediting bodies, VISN, VHA, and organizational leadership.

Managing Joint Commission unannounced surveys, CARF surveys, and OIG Comprehensive Assessments, including communication plans, document control, and logistical coordination.

Driving staff education and engagement to ensure ongoing compliance and readiness across all sites.

The Continuous Survey Readiness and Accreditation Program ensures the organization meets standards consistently.

Success is measured through ongoing accreditation, timely implementation of new standards, completion of PPRs, action plans, and data-driven outcomes.

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 Preferred Experience Demonstrated leadership in accreditation readiness and compliance programs within a healthcare setting, including experience with Joint Commission, CARF, and OIG survey processes.

Proven ability to develop and implement proactive strategies for continuous survey readiness and regulatory compliance.

Strong analytical and problem-solving skills, with a track record of using data to drive process improvements and achieve measurable outcomes.

Experience in collaborating across multiple services and disciplines, fostering teamwork and accountability to meet organizational goals.

Ability to communicate effectively with internal stakeholders and external accrediting bodies, including preparing and submitting required documentation.

History of leading organizational change initiatives, demonstrating creativity and adaptability in complex healthcare environments.

Skilled in staff education and engagement, ensuring timely dissemination of new standards and fostering a culture of compliance.

Evidence of being a self-driven, highly motivated professional who takes ownership, maintains a positive attitude toward challenges, and consistently seeks solutions.

Experience in project management or program coordination, particularly in quality management or accreditation programs.

Work Schedule: Monday-Friday 8:00am-4:30pm Telework: Adhoc telework maybe considered based on service needs, on a case by case basis Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized