Nurse Practitioner (Behavioral Health Quality & Accreditation Program Coordinator)

Veterans Health Administration • Salt Lake City, UT

7d • Onsite

About The Position

The Nurse Practitioner Behavioral Health Quality & Accreditation Program Coordinator provides expert-level leadership in 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 leads or collaborates on policy-making related to customer service and the operation of administrative and clinical programs. The position also establishes and maintains cross-service and cross-disciplinary programs that support organizational mission and health care.

The coordinator chairs the Behavioral Health Quality and Compliance Committee, which includes Mental Health Executive Leadership and the Chief of Quality, Safety, and Value. The role leads monitoring and analysis of performance trends, improvement efforts, and continuous compliance across Behavioral Health Services. It also coordinates accreditation readiness and responses, including the medical center's Focused Standards Assessment for The Joint Commission, post-survey requirements such as Evidence of Standards Compliance and Measures of Success, and oversight of an external review database. The coordinator analyzes and shares regulatory findings and communications with leadership, and generates and disseminates data from mock surveys, tracer activities, peer reviews, and other quality oversight processes to support decisions and sustainable improvement.

The position requires an active, unrestricted Nurse Practitioner license and current board certification in a clinical specialty. Nurse IV qualification requires the specified graduate education, professional nursing experience, specialized experience, and leadership dimensions. The position is located at the VA Salt Lake City Health Care System and is not virtual; limited ad-hoc telework may be available.

Requirements

• Graduate of a professional nursing school approved by an appropriate accrediting agency and accredited by ACEN or CCNE at the time the program was completed, or qualifying equivalent foreign education.
• Post-master's certificate, master's degree, or doctoral degree as a Nurse Practitioner.
• Active, current, full, and unrestricted Nurse Practitioner license in a U.S. State, Territory, Commonwealth, or the District of Columbia.
• Full and current board certification in a clinical specialty from ANCC, AANPCB, or another nationally recognized certifying body in the area of academic preparation.
• For Nurse IV: meet the scope and dimension criteria and one of the specified education and experience pathways: MSN plus four years of professional nursing experience, including one year of specialized experience equivalent to Nurse III; a related master's degree with BSN plus the same experience; doctoral nursing degree plus three years of professional nursing experience, including one year of specialized experience equivalent to Nurse III; or a related doctoral degree with BSN plus the same experience.
• U.S. citizenship, except that non-citizens may be appointed when qualified citizens cannot be recruited under VA policy.
• English proficiency for direct patient care, including basic written and spoken English.
• Pass required pre-employment screening, including applicable urinalysis, background/security investigation, and physical evaluation.
• Meet Selective Service registration requirements, if applicable.
• Participate in the seasonal influenza vaccination program.
• Ability to perform the position's physical activities without restriction, including considerable standing, walking, stooping, bending, reaching, lifting, and turning; pushing or lifting more than 50 pounds; climbing stairs; working with arms above shoulder level or the neck flexed or extended; protecting oneself from physically abusive patients; and traveling by automobile for several hours.
• Visual and auditory acuity sufficient to provide safe and effective care.

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 expected functions and activities.
• Contribute ideas and recommendations for standards of care, policies, and objectives to enhance clinical practice.
• Lead and collaborate in policy-making activities related to customer service and the functioning of administrative and clinical programs.
• Collaborate with health care staff to establish and maintain cross-service and cross-disciplinary programs that influence organizational mission and health care.
• Chair the Behavioral Health Quality and Compliance Committee.
• Monitor and analyze performance trends, guide improvement efforts, and maintain continuous compliance with accreditation and regulatory standards across Behavioral Health Services.
• Lead Behavioral Health accreditation readiness and response, including coordination of 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.
• Analyze and disseminate findings and communications from regulatory bodies, including TJC, OIG, and OMI, 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 up to 5% in contributions by VA.
• 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