Accreditation and Regulatory Specialist

Vanderbilt University Medical Center•Nashville, TN

About The Position

The Accreditation and Regulatory Specialist supports 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 across Vanderbilt Health. The specialist uses data analytics to identify potential regulatory risks, helps develop corrective action plans with unit leadership, and may initiate or advise on policy drafts and revisions. The role facilitates review, response, and documentation of complaints from external parties, supports additional licensures, accreditations, and certifications across the health system, and may assist with regulatory visits. Additional duties may be assigned. The position is part of the Department of Quality, Safety, and Risk Prevention, which supports Vanderbilt Health faculty and staff across the Main Campus, Regional Hospitals, and Ambulatory Divisions in delivering safe, timely, effective, efficient, and patient-centered care. The role calls for relevant work experience, with an experience level of two years and a bachelor's degree listed.

Requirements

Bachelor's degree.
Two years of experience level is listed.
Knowledge of healthcare data analysis, including locating, validating, extracting, and formatting data; modifying and running queries and standard reports; identifying data values and sources; and understanding relationships between data items.
Knowledge of regulatory compliance and the ability to interpret and explain rules and regulations in complex situations.
Project management capability, including planning, organizing, and managing resources to achieve project goals.

Nice To Haves

Accreditation and regulatory experience is strongly preferred.
Nursing experience is preferred but not required.
Some project management experience is preferred.

Responsibilities

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