Accreditation and Regulatory Specialist

Vanderbilt University Medical Center•Nashville, TN

About The Position

The Accreditation and Regulatory Specialist ensures organizational compliance by interpreting, implementing, and monitoring adherence to complex federal and state regulations. The role collaborates across departments to identify compliance gaps, mitigate institutional risk, and support continuous quality improvement initiatives across Vanderbilt Health. The Department of Quality, Safety, and Risk Prevention equips and empowers faculty and staff across the Main Campus, Regional Hospitals, and Ambulatory Divisions to provide safe, timely, effective, efficient, and patient-centered care. Its teams share knowledge, extend best practices, reduce variability, and improve outcomes throughout the health system.

Requirements

Bachelor's degree.
Two years of relevant work experience.
Accreditation and regulatory experience strongly preferred.
Nursing experience preferred, but not required.
Some project management experience preferred.
Intermediate healthcare data analysis capability, including locating, validating, extracting, and formatting data; modifying and running queries and standard reports; identifying data values and sources; and understanding data relationships.
Intermediate regulatory compliance capability, including applying, interpreting, and explaining rules and regulations in complex situations and guiding or training others in their interpretation.
Novice regulatory strategy capability, including preparing plans for regulatory requirements, forecasting resource needs and risks, identifying stakeholders, and building commitment around shared goals.
Novice regulatory documentation capability, including preparing clear, comprehensive documentation that follows technical conventions and governmental requirements.
Intermediate project management capability, including planning, organizing, and managing resources to achieve project goals and objectives.

Nice To Haves

Nursing experience.
Some project management experience.
Accreditation and regulatory experience.

Responsibilities

Use proactive data analytics to identify potential regulatory risks.
Help draft and implement corrective action plans with unit leadership.
May initiate and advise on policy drafts and revisions.
Facilitate the review, response, and documentation of complaints received from external parties, with occasional guidance.
Facilitate obtaining additional licenses, accreditations, and certifications across the health systems.
May assist with regulatory visits.
Perform additional duties as assigned.