GME Accreditation and Compliance Program Manager

University of Colorado•Hybrid, CO

8d•$63,554 - $85,162•Hybrid

About The Position

The position is one of three full-time Accreditation and Compliance Program Manager team members (along with one professional services team member) who work collaboratively to ensure regulatory compliance for the University of Colorado School of Medicine (CU SOM) Graduate Medical Education (GME) Residency and Fellowship training programs. Members of this team function as institutional experts on Accreditation Council for Graduate Medical Education (ACGME) requirements for maintenance of accreditation at both the institutional and specialty-specific levels. Accreditation and Compliance Program Managers assure that programs deliver effective educational programming and engage in adequate clinical activities to meet the regulatory requirements of the ACGME, its individual specialty/subspecialty Review Committees (RCs), as well as the requirements of the School of Medicine and the Office of the Associate Dean for Graduate Medical Education. The position provides Program Directors (physicians) and Program Coordinators (non-physicians) with educational strategies and methods designed to meet the requirements for maintenance of accreditation and to achieve excellence in education and program administration. The Accreditation and Compliance team is responsible for ensuring that approximately 118 Graduate Medical Education physician training programs at the University of Colorado School of Medicine maintain accreditation by the Accreditation Council for Graduate Medical Education (ACGME). In addition to the accredited programs, this position provides GME oversight of approximately 112 non-ACGME-accredited GME fellowship programs. The position provides essential and required communication to stakeholders, including program coordinators, program directors, department chairs, teaching faculty, and residents/fellows.

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 Graduate Medical Education (GME), academic medicine, healthcare administration, or a related field, including at least three (3) years supporting or managing ACGME-accredited residency and/or fellowship programs.
Proven experience in leading and managing in a highly accountable work environment
An advanced degree (Masters or Doctorate) may be substituted for experience on a year for year basis if the degree is in a field of study directly related to the work assignment.
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)

Nice To Haves

Professional experience in Graduate Medical Education within an ACGME-accredited Sponsoring Institution, with progressively responsible duties related to institutional compliance, program administration, and accreditation.
Experience supporting a Designated Institutional Official (DIO), Graduate Medical Education Committee (GMEC), or institutional GME office.
Experience coordinating ACGME accreditation activities, including new program applications, ADS Annual Updates, institutional or program site visits, Annual Program Evaluations (APEs), Special Reviews, and accreditation progress reports.
Experience interpreting and applying ACGME Institutional Requirements, Common Program Requirements, and Specialty-Specific Program Requirements.
Experience developing compliance metrics, dashboards, policies, procedures, templates, or educational resources to support GME accreditation and continuous quality improvement.
Experience providing consultation, education, or training to Program Directors, Associate Program Directors, and Program Coordinators on accreditation and regulatory requirements.
Master's degree or other advanced degree from an accredited college or university in higher education administration, healthcare administration, public administration, business administration, or a closely related field.

Responsibilities

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.
Educate program directors and coordinators on their specialty-specific and institutional ACGME requirements.
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.
Ensure that programs provide current information to ACGME within the regulatory guidelines and deadlines through a formal annual Accreditation Data System (ADS) Annual Update, and on an ongoing basis throughout the year, as required.
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.
Develop and maintain expertise in continuously evolving regulatory requirements including ACGME Common, Specialty-specific Program Requirements and Institutional Requirements.
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 (GMEC) 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 Accreditation Data System (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 ~112 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.
Lead organization of semi-annual half-day GME Essentials orientation for new program directors and associate program directors.
Perform a variety of special projects to support departmental, institutional, and ACGME initiatives, such as FTE data collection and assistance with GME Leadership Retreat planning and execution.
Coordinate annual institutional Program Director and Program Coordinator Excellence Award process.
Participate in GME long-range and short-term strategic planning.