Assistant Director of Accreditation - Housestaff

Assistant Director of Accreditation - House staff

Job no: 541156
Work type: Staff Full-Time
Location: Main Campus (Gainesville, FL)
Categories: Education/Training/Instructional Design
Department:  - MD-HOUSESTAFF

Classification

Title:

AST DIR, Education/Training Programs

Job Description:

The Assistant Director of Accreditation provides operational leadership for the accreditation and continuous quality improvement functions of the University of Florida College of Medicine Graduate Medical Education (GME) Office. Reporting to the GME Director of Administration, this position manages a major segment of the institution's education and training operations and supports the oversight of ACGME-accredited residency and fellowship programs, including ACGME Non-Standard Training (NST) programs, within a large, complex academic medical center.

The Assistant Director serves as a institutional resource for accreditation standards, program review, policy implementation, and program improvement. The position translates accreditation requirements into practical guidance, coordinates institutional review and monitoring activities, supervises assigned professional and support staff, and partners with program directors, coordinators, faculty, and GME leadership to promote consistent and sustainable compliance. As part of the GME leadership team, the Assistant Director is cross-trained in the Director's core accreditation responsibilities and provides leadership continuity for assigned functions when delegated or during the Director's absence.

About This Role:

Accreditation Oversight and Program Consultation

• Direct day-to-day accreditation support and consultation for assigned GME programs and institutional functions.
• Interpret and apply ACGME Institutional, Common Program, and specialty-specific requirements; provide timely, consistent guidance to program directors, coordinators, faculty, and GME staff.
• Manage routine accreditation monitoring activities, including review of program letters, citations, Areas for Improvement, accreditation statuses, action plans, and required institutional follow-up.
• Monitor institutional compliance with Program Letters of Agreement (PLAs) and provide oversight of the PLA process, including review of status reports, identification and escalation of gaps or expired agreements, and verification that designated staff and programs complete required actions.
• Provide institutional support and operational oversight for ACGME NST programs, including interpretation of applicable requirements, ongoing compliance monitoring, and guidance to program and department leadership.
• Develop and maintain accreditation resources, templates, calendars, standard operating procedures, and communication tools that support consistent institutional practices.
• Identify emerging compliance risks, recommend corrective strategies, and elevate significant or systemic concerns to the Director, Associate DIO, and DIO as appropriate.
• Serve as a liaison between the GME Office, clinical departments, program leadership, and institutional stakeholders on assigned accreditation matters.

Program Review, Applications, and Site Visit Readiness

• Coordinates complex program review and accreditation-readiness activities from planning through follow-up.
• Coordinate institutional preparation for ACGME institutional and program site visits, focused reviews, self-studies, and other accreditation-related reviews.
• Review draft new program applications, complement increases, participating site additions, program changes, and related submissions for completeness, internal consistency, and alignment with institutional expectations.
• Assist with the development, institutional review, and submission of new ACGME NST program applications and renewals, and coordinate preparation for NST-related site visits, reviews, and required follow-up.
• Provide structured consultation to programs preparing responses to citations, requests for progress reports, adverse actions, or other ACGME communications.
• Conduct targeted audits of accreditation records and program documentation; track findings, responsible parties, deadlines, and completion of corrective actions.
• Maintain readiness materials and standardized processes that allow the GME Office to respond efficiently to planned and unplanned accreditation activity.

Committee Operations and Institutional Governance

• Lead or support GME committee processes that advance institutional oversight and regulatory compliance.
• Manage the operational work of assigned GMEC subcommittees, including agenda development, document review, presentation of findings, action tracking, and maintenance of an auditable record.
• Support the Accreditation Requirements Review Committee (ARRC) and other assigned committees; chair meetings or work groups when delegated by the Director.
• Oversee the operational work of the NST Committee, including application review, agenda and meeting coordination, documentation of decisions, action tracking, and communication with programs and…