Nurse; Accreditation Program Manager

Position: Nurse (Accreditation Program Manager)
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.

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