Accreditation and Compliance Manager

University of Colorado

1d•Hybrid

About The Position

The position manages 115+ Graduate Medical Education (GME) physician training programs at the University of Colorado School of Medicine to maintain accreditation through the Accreditation Council for Graduate Medical Education (ACGME). This includes overseeing the delivery of high-quality educational programming and clinical training activities that meet all regulatory requirements established by the ACGME and its specialty and subspecialty Review Committees (RCs). This role provides leadership and oversight of the GME Accreditation and Compliance team, which consists of institutional accreditation and compliance program managers and professionals who serve as subject matter experts on ACGME institutional and program-level requirements. The team collaborates closely with training programs to ensure ongoing regulatory compliance across all residency and fellowship programs. The position is also responsible for advising physician program directors on effective educational strategies and methodologies to support continued accreditation. In addition to accredited programs, the role provides oversight for 100+ non-ACGME-accredited GME fellowship programs. Furthermore, the position ensures consistent, accurate, and timely communication with key stakeholders, including program coordinators, program directors, department chairs, teaching faculty, and residents and fellows. This position is critical to the success of the Graduate Medical Education program at the University of Colorado, providing strategic leadership to the team, guiding stakeholders and ensuring oversight of processes, data, innovation and compliance with ACGME.

Requirements

Bachelor’s degree in education, psychology, business, public administration, health care, educational technology, social science, liberal arts, communications, accounting, finance, library science, or a directly related field from an accredited institution and 4-6 years of professional experience in accreditation, program management, project management and of the total years of experience, 1-2 years of which must have included direct management of full-time equivalent professional staff.
Applicants must meet minimum qualifications at the time of hire.
Ability to communicate effectively, both in writing and orally.
Ability to establish and maintain effective working relationships with employees at all levels throughout the institution.
Outstanding customer service skills.
Knowledge of and ability to apply regulatory requirements for accreditation of graduate medical education training programs at the institutional and program level
Ability to apply accepted theories, practices and principles relating to the development and implementation of methods to ensure appropriate curriculum and assessment of performance for graduate medical education training programs and trainees
Demonstrated ability to establish work priorities, research and resolve problems, delegate assignments as appropriate and follow through to ensure completion of activities
Skills in analyzing and interpreting policies, procedures, reports, and data
Proven attention to detail and accountability
Ability to plan, organize, implement and coordinate educational and administrative activities
Demonstrated initiative, resourcefulness and creativity in problem-solving
Ability to work collaboratively as a team with all members of the office staff to accomplish the goals and objectives of the institution
Ability to work with and communicate effectively with individuals with diverse training and backgrounds as well as all levels of management in both written and spoken communication
Demonstrated ability to utilize specialized software programs
Demonstrated proficiency with Microsoft programs (MS Word, Excel, PowerPoint and Outlook)
Applicants must be legally authorized to work in the United States without requiring sponsorship. We are unable to provide work visa sponsorship and employment authorization for this position now or in the future.

Nice To Haves

Master’s degree in education, psychology, business, public administration, health care, educational technology, social science, liberal arts, communications, accounting, finance, library science, or a directly related field from an accredited institution.
Professional experience in Graduate Medical Education in an academic institution with responsibility for program administration and accreditation.

Responsibilities

Serve as liaison and leadership representative to internal and external entities when GME accreditation expertise is needed.
Hire Accreditation and Compliance staff and oversee the onboarding and training of team members to ensure they are properly trained and equipped to successfully complete assigned job duties.
Provide direct supervision to three (3) or more full-time exempt professionals.
Ensure effective communication and exceptional customer service from the team to faculty, staff, residents, fellows, and stakeholders both internal and external to the university.
Handle workload assignments, performance management, coaching and counseling, and leave management for direct reports.
Review existing processes to identify opportunities for increased efficiency and effectiveness.
Identify opportunities for innovation, including utilizing technology to reduce administrative burden.
Collaborate with GME Director for Operations and Strategy to identify and improve workflows that cross operational and accreditation functions.
Coordinate annual institutional Program Director and Program Coordinator Excellence Award process.
Participate in GME long-range and short-term strategic planning.
In collaboration with program directors and coordinators, complete extensive GMEC and ACGME accreditation applications to establish new residencies and fellowships, ensuring alignment with institutional policies and ACGME accreditation standards.
Site visit preparation: Organize and perform timely Midpoint Initial Accreditation Reviews and Mock Site Visits to help programs identify and address areas for improvement leading up to their ACGME site visit. Participate in site visit interviews alongside DIO.
Educate program directors and coordinators on their specialty-specific and institutional ACGME requirements.
Lead organization of semi-annual half-day GME Essentials orientation for new program directors and associate program directors.
Oversee each program’s compliance with GME and ACGME requirements through review of the ACGME program’s Annual Program Evaluation. Issue a comprehensive compliance metrics dashboard to each ACGME program annually. Create additional dashboards by department and at the institutional level
Ensure that programs provide current information to ACGME within regulatory guidelines and deadlines through a formal annual Accreditation Data System (ADS) Annual Update, and on an ongoing basis throughout the year, as required.
Develop and maintain expertise in continuously evolving regulatory requirements including ACGME Common, Specialty-specific Program Requirements and Institutional Requirements.
Oversee Accreditation and Compliance data and reporting
Review & revise annually relevant GME policies and procedures impacting all GME programs, ensuring they are updated with any new regulatory requirements.
Prepare institution for and participate in institutional-level site visits from ACGME.
Organize, with the Associate Dean for GME, the monthly Graduate Medical Education Committee meetings, and monthly GMEC Subcommittee meetings and ensure that the content and membership satisfy ACGME requirements. Provide oversight of Subcommittee meeting agenda, minutes, membership management, and contribute to maintaining Subcommittee Charters and appointment of Chairs and Vice Chairs. Serve as voting member of GMEC.
Create GME templates using internal best practices and/or national outstanding models to assist the institution and the GME programs in meeting and exceeding compliance with ACGME standards.
Write the Annual Institutional Report in collaboration with the Associate Dean for GME/DIO and prepare slides for DIO presentation of the Report.
Submit annual institutional ADS update to ACGME.
Organize and participate in Special Reviews, as a member of the review team. Draft resulting reports and monitor program’s progress with corrective actions through required Progress Reports.
Track Accreditation Citations and Areas for Improvement (AFIs), guiding programs through Progress Reports until they meet standards.
Partner with prospective new non-ACGME-accredited programs to complete extensive GMEC applications to establish new residencies and fellowships, in compliance with all requirements.
Oversee, as part of three-member team, ongoing compliance with GME policy for ~110 non-accredited medical fellowships programs, including review of changes in program leadership, resident complement, and modifications to the original program description. For non-ACGME programs accredited by an external organization, oversee compliance to the extent required of the institutional DIO.
For ~25 programs with Non-Standard Training (NST) recognition, ensure compliance with additional ACGME NST requirements.
Perform a variety of special projects to support departmental, institutional, and ACGME initiatives, such as FTE data collection, assistance with GME Leadership Retreat planning and execution, orientation and onboarding and other projects as assigned.