Job Summary

The University of Illinois at Chicago, UI Health and Sciences System is looking to hire a qualified candidate to fill the role of Accreditation and Regulatory Specialist within the the Department of Graduate Medical Education. Under the administrative supervision of Graduate Medical Education (GME) leadership, this role contributes to residency program oversight by taking a leading role in coordination, measurement, analysis, reporting, and project management pertinent to the accreditation and program review processes. It also collaborates with the GME Office team and key organizational members to monitor and identify needs in response to the Accreditation Council for Graduate Medical Education (ACGME) and other regulatory agency compliance standards. In addition, this role will provide recommendations for and participates in, as appropriate, the development and execution of strategies that support a culture of continuous compliance and quality improvement.    

Essential Duties/Responsibilities 

• Regularly review for GME compliance the ACGME current and pending requirements, University of Illinois Health Sciences System (UIH-HSS) policies and guidelines, and Illinois state regulations.  Keep abreast of best practices and trends to assess the potential impact on organizational processes.  Research external sources for compliance strategies.  
• Collaborate in the identification of regulatory compliance gaps for mitigation and development of mechanisms for internal control and measurement.  Monitor ACGME submissions, as requested.  Prepare narrative and statistical reports to direct focus to critical areas for procedural adherence and continuous readiness for surveys and site visits.   
• Analyze regulatory/rule changes to ensure they are communicated through multiple mechanisms, including policies and procedures.  Draft revisions and/or formulate new policies for review and approval by the Graduate Medical Education Committee (GMEC).   Recommend the means by which these may be implemented and integrated.
• Manage and maintain all GME policies through review of existing policies, creation of online directories, and reconciliation with hospital policies.  Contribute to the development and revision of related manuals.       
• Review GME and ACGME program and institutional evaluations.  Develop and conduct surveys to obtain additional information, as needed.  Integrate and synthesize data, conduct quantitative and qualitative analyses and identify trends.  Compose summaries and reports and/or make recommendations to senior management based on analysis of data.     
• Facilitate ongoing transition of program and GME data collection to New Innovations (NI) residency management software with the objective of streamlining production of essential reports for GME oversight and program review.  Function as a resource and collaborate with relevant administrative personnel to coordinate implementation.  Identify and trouble-shoot problems.
• Evaluate the annual program review process for continuous operational improvement and effective software utilization.  Oversee submission of evaluations, conduct preliminary review and request supporting documentation, as needed.  Extrapolate data that can be used to drive strategy and quality improvement.
• Provide administration, communications, material preparation and coordination of special program reviews and duty hours/work environment audits.  Attend, participate and contribute, as requested.  Assist with development, editing and formatting of reports and summaries.  Maintain and monitor comprehensive schedule for GMEC presentations and follow-up activities in adherence to recommended timeframes.  
• Establish and serve on associated task forces and work groups.  Ensure that the RWEC is in continuous alignment with its established purpose and GMEC directives.  Prioritize activities in accordance with ACGME requirements.  Engage and partner with the appropriate personnel / departments to provide relevant input, address issues and achieve resolutions.  Manage scheduling and communications.  Formulate action plans and conduct follow-up.  Develop, distribute, and retain agendas, meeting minutes and other relevant materials. 
• Provide ongoing daily support to the residents, fellows, program coordinators and program directors, serving as point of contact and facilitator regarding work environment concerns.  Ensure issues are accurately identified and documented, forwarded or addressed collaboratively, as appropriate, and monitored for outcome and resolution.
• Provide impetus and organization for establishment of additional GMEC sub-committees, as requested.  Draft descriptions for GMEC approval.  Assume responsibilities for scheduling, communications, agendas, minutes, action plans and follow-up.  Function as GMEC representative for reports and serve as committee co-chair, as needed.   
• Draft, distribute and maintain GMEC correspondence relative to actions taken. 
• Assist with various GME meetings, program consultations, and new resident/new program director orientations with regard to scheduling, logistics, agenda and/or material preparation, review and follow-up.  
• Facilitate efficient management and retention of records. 
• Contribute to website content and revision. 
• Support leadership with and, at times, work independently on special projects and additional accreditation, program review and quality improvement activities.  Work with leadership to explore ways to facilitate intra and interdepartmental cooperation for improved processes to maintain ACGME compliance and ensure integration of efforts to achieve common goals. 
• Perform other duties, as assigned. 

Minimum Acceptable

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. Bachelor's degree required in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science, or other discipline related to the Healthcare field.
2. Two (2) years (24 months) of work experience with the standards and survey process of an organization that includes accreditation.

* As required by the position to be filled, education, training and/or work experience in the area of specialization inherent in the position may be required in meeting credential requirements #1 and #2 above.

**Applicants possessing a Master's degree in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science or other discipline related to the Healthcare field meet the requirements of #1 above.

Preferred Qualifications

ACGME accreditation, regulation, and requirements experience/knowledge preferred

To Apply: For fullest consideration, please fully complete an online application by clicking the Apply for Position button below.

Fully complete all sections of the online application including adding your full work history with specific details of your duties & responsibilities for each position held. Fully complete the education, licensure, certification and language sections.

You may upload a resume, cover letter, certifications, licensures, transcripts and diplomas within the document section of your online application.

All civil service positions require an exam.  The exam for this position is a Credentials Assessment.  You will not be required to report in person for this exam.

Credential Assessment Exam Scoring Information:

You will not be required to report in person for this exam. The updated online application and all uploaded, relevant documents, such as a resume, college transcript, certifications and licensures will be used in the calculation of the exam score. These documents should be uploaded prior to the position close date.

When completing your online application, please be sure to provide detailed information about your job knowledge and specific duties and responsibilities, as your qualifications for any Civil Service position will be primarily determined based on what is contained in the application. Dates of employment and if employed on a full or part time basis (including number of hours per week) must be indicated for each position held. Additional consideration will be given to supporting documentation i.e. resume, transcripts, licenses, and certifications so please be sure to attach all applicable documents.

For additional information regarding this position please contact kbridgey@uic.edu.

If an application is not fully completed and submitted by the close date, the applicant/employee will not be considered for this position.

For fullest consideration, the above mentioned requirements must be submitted no later than Tuesday, July 5, 2022.

We appreciate your interest in employment at the University of Illinois at Chicago.

The University of Illinois is an Affirmative Action/Equal Opportunity Employer.

This position requires Illinois residency within 180 days of the hire date.

University of Illinois faculty, staff and students are required to be fully vaccinated against COVID-19. If you are not able to receive the vaccine for medical or religious reasons, you may seek approval for an exemption in accordance with applicable University processes.

For classifications that require a degree as part of the minimum qualifications, a degree verification will be required before any offers of employment are extended.