Nurse Practitioner (Behavioral Health Quality & Accreditation Program Coordinator)

Veterans Health Administration • Salt Lake City, UT

2d • Hybrid

About The Position

The Nurse Practitioner Behavioral Health Quality & Accreditation Program Coordinator provides expert-level leadership for planning, coordinating, implementing, and monitoring performance improvement activities across Behavioral Health Services at the VA Salt Lake City Health Care System. The position drives compliance and organizational readiness with The Joint Commission, the Office of Inspector General, VHA guidelines and directives, and other applicable regulatory bodies.

The coordinator supports nurse leaders, advanced practice nurses, and interdisciplinary clinicians; contributes to standards of care, policies, and clinical-practice objectives; and collaborates on policy-making related to customer service and administrative and clinical programs. The role also collaborates across services and disciplines on programs that advance the organization’s mission and health care.

Requirements

• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by ACEN or CCNE when the program was completed, or meet the stated equivalent-education provisions.
• Post-master’s certificate, master’s degree, or doctoral degree as a Nurse Practitioner.
• Active, current, full, and unrestricted APN license to practice as a Nurse Practitioner in a U.S. state, territory, commonwealth, or the District of Columbia.
• Full and current basic board certification as a Psychiatric-Mental Health Nurse Practitioner from ANCC, AANPCB, or another nationally recognized certifying body in the area of academic preparation.
• Meet Nurse IV scope, education, and dimension criteria: qualifying education and professional nursing experience, including specialized nursing experience equivalent to Nurse III, as specified in the announcement.
• For Nurse IV, qualifying education and experience include one of the stated pathways: MSN and four years of professional nursing experience; a related master’s degree with a BSN and four years; a nursing doctoral degree and three years; or a related doctoral degree with a BSN and three years. Each pathway requires one year of specialized experience equivalent to Nurse III and meeting Nurse IV dimension requirements.
• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• English proficiency for direct patient care.
• Pass required pre-employment screening, including urinalysis for applicants selected for testing-designated positions, background/security investigation, and physical evaluation.
• Meet Selective Service registration requirements, if applicable.
• Complete the required online onboarding and application requirements; provide acceptable identification.
• Participate in the VA seasonal influenza vaccination program.
• Two years of experience with Mental Health Quality and Safety Compliance (e.g., The Joint Commission or OIG).
• Experience providing care to Veterans with serious mental illness.
• Ability to perform the position’s physical activities without restriction, including substantial standing, walking, stooping, bending, reaching, lifting, and turning; potentially pushing or lifting over 50 pounds; climbing stairs; maintaining required visual and auditory acuity; working with arms above shoulder level or the neck fully flexed or extended; physically controlling or protecting oneself from abusive patients; and traveling by automobile for several hours.

Nice To Haves

• Two years of experience with Mental Health Quality and Safety Compliance, such as The Joint Commission or OIG.
• Experience providing care to Veterans with serious mental illness.

Responsibilities

• Assist Nurse Leaders, Advanced Practice Nurses, and interdisciplinary clinicians in carrying out their functions and activities.
• Contribute ideas and recommendations for standards of care, policies, and objectives that enhance clinical practice.
• Lead and collaborate in policy-making related to customer service and the overall functioning of administrative and clinical programs.
• Collaborate with health care staff to establish and maintain programs that cross services or disciplines and influence organizational mission and health care.
• Chair the Behavioral Health Quality and Compliance Committee, comprising Mental Health Executive Leadership and the Chief of Quality, Safety, and Value.
• Lead the committee in monitoring and analyzing performance trends, guiding improvement efforts, and maintaining continuous compliance with accreditation and regulatory standards across Behavioral Health Services.
• Lead Behavioral Health accreditation readiness and response, including coordinating the medical center’s Focused Standards Assessment for The Joint Commission.
• Manage post-survey requirements, including Evidence of Standards Compliance and Measures of Success, and oversee an external review database.
• Ensure findings and communications from regulatory bodies, including TJC, OIG, and OMI, are analyzed and disseminated to leadership in a timely and actionable manner.
• Generate, analyze, and disseminate data from mock surveys, tracer activities, peer reviews, and other quality oversight processes to inform decisions and drive sustainable improvement.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year: 26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Traditional federal pension with five-year vesting.
• Federal 401(k), with VA contributions up to 5%.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior