Summary

This Registered Nurse (Quality Management Accreditation Specialist) position is located in the Quality and Patient Safety Services at the Leeds, MA location and reports directly to the Chief of Quality Management, in line to the Medical Center Director.

This position is full time at 40 hours per week.

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

Duties

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Duties Include but not limited to:

Responsible for planning, organizing, initiating and directing activities related to survey/inspection readiness and accreditation for the OIG, TJC, CARF, and other accrediting/regulatory bodies. The position must exhibit leadership that is characterized by responsibility and accountability for continued implementation, utilization, and evaluation of the facilities programs in risk management, clinical analysis, patient safety, utilization with a primary focus in accreditation. Experience interacting with regulatory bodies such as TJC, OIG, CARF, in addition to employees at the Veteran Integrated Service Network (VISN) 1. This position must perform duties directly contributing to the administrative management of a healthcare delivery system that requires the ability to apply the specialized principles and practices of health care management in directing or supporting a health care delivery system. He/she serves as a staff member directly supporting the Accreditation & Regulatory Programs and management teams responsible for planning, organization, development, direction, and evaluation of the Medical Center. Must possess comprehensive knowledge in principles and practice of the health care field with emphasis on quality, safety, utilization, and performance improvement with strong skills in consulting, education, database and information management, evaluation techniques, group process, team and organizational development, and customer service and satisfaction. Quality activities include knowledge, application skills and support of quality programs such as risk management, clinical analysis, document control and patient safety. This position also functions as a subject matter expert on committees and services regarding accreditation and regulatory activities. Works closely with the Quality Manager and service leaders providing guidance in survey preparation and follow-up.

Work Schedule: Monday to Friday, 8:00 a.m. to 4:30 p.m.

Telework: Not Available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

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

Notifications:

• This position is in the Excepted Service.
• This position is covered by a special rate.
• The salary is based on the grade and step approved for the selected candidate.
• Veterans' preference does not apply for internal or other current permanent Federal agency employees.
• The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below
• If you are a current federal employee, you are required to attach your Most Recent non-award SF-50. This should be a SF-50 from the current calendar year which shows your current position, grade and step. Award SF-50's do not provide sufficient information and will not be accepted.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards

Requirements

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Conditions of employment

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• You may be required to serve a probationary period.
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

Qualifications

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/[redacted].

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:

• Experience working in Quality Management within a healthcare environment
• VA or other Federal Service experience
• Excellent communication
• Stakeholder engagement skills
• Ability to demonstrate expertise in healthcare accreditation readiness and compliance
• Experience interpreting and applying Joint Commission and VA regulatory standards.
• Strong skills in conducting audits, leading gap analyses, and coordinating survey activities across multidisciplinary teams.
• Ability to review policies and procedures, access organizational compliance and support performance improvement initiatives

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

Physical Requirements: All applicants must be physically able to satisfactorily perform the duties of the position. A pre-placement physical examination shall be completed prior to appointment.

Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.The Associate Degree Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science degree in Nursing (MSN) must be fully accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission On Collegiate Nursing Education (CCNE). Verification of accreditation may be obtained from http://www.acenursing.us/accreditedprograms/programsearch.htm or https://directory.ccnecommunity.org/reports/accprog.asp.

• If your school has changed names, or is no longer in existence, you must provide this information in your application.
• If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet.

Additional information

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.