Graduate Medical Education Accreditation Specialist

What Makes Us Different

At FMOL Health we offer you so much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital we are here to create a spirit of healing. We offer you something special - the chance to do Gods work by helping to serve people in need throughout our community every day.

Job Summary

The GME Accreditation Specialist is responsible for maintaining oversight of the accreditation process for each individual specialty program as well as institutional accreditation for accredited hospitals within our entire health system. This role involves coordinating accreditation processes maintaining documentation and supporting program directors and residents to achieve and maintain accreditation status. Additionally the specialist will oversee the clinical learning environment for the institutions. The GME Accreditation Specialist will also hold responsibilities in the academic affairs department to ensure compliance with accreditation standards.

Minimum Requirements

Experience -5 years of work experience in a healthcare or academic setting.

Education -Bachelors Degree required in Education Healthcare or Business Administration Nursing Allied Health or related field.

Apply now! Here you are more than an employee. You are a team member a co-worker our friend and part of our family. Our healthcare team is working together to heal this community one patient at a time!

and assist in the implementation of standardized processes for the accreditation process for the institution residency and fellowship programs across the System.
and ensure all system residency and fellowship programs meet relevant accreditation standards including ACGME to maintain the quality of our educational programs.
as a central point of contact for all regulatory and accreditation matters providing clear and consistent guidance to hospitals within our system.
regulatory and accreditation requirements with hospitals ensuring they are well-informed and prepared for accreditation reviews and audits.
compliance with ACGME Joint Commission and other relevant accrediting bodies.
accreditation activities including ACGME Site Visits.
ongoing readiness and continuous improvement of the institutional learning environment ensuring it meets the highest standards of educational excellence for the ACGME Annual Institutional Review (AIR).
the Designated Institutional Officer in all correspondence with ACGME at the institutional and program levels including the Annual Institutional Review (AIR) and the Annual Program Evaluation (APE).
residency program citations and program action plans to address ACGME citations.
and implement strategies for continuous improvement in GME programs.
Learning Environment
on continuous improvement and management of the institutional and clinical learning environments ensuring they meet the highest standards of educational excellence and accreditation requirements.
and ensure ACGME Annual Resident Fellow and Faculty Surveys are completed by the annual deadline.
and review all surveys including the Institutional Survey.
policies and delineation of privileges.
with the creation and oversight of departmental affiliation agreements. Ensure that all agreements align with the organizations goals and regulatory requirements and prioritize partnerships with quality institutions to strengthen the workforce pipeline.
appropriate and frequent communication between affiliated institutions residency programs and Academic Affairs supporting the Director of Academic Affairs and Designated Institutional Officer.
and Reporting
accurate and up-to-date records of accreditation-related documentation.
and maintain all ACGME-related files.
and ensure the policies from each sponsored program are maintained updated reviewed and approved by Legal.
each sponsored programs Annual Program Evaluations and collaborate with the DIO and program coordinator on action items.
executive summary of Annual Institutional Report (AIR) and assist with yearly update to the board.
proficient in using New Innovations and pull reports as necessary
accurate GME Resident and Fellow personnel online records and credentialing documentation which must be accurate present and in order to ensure continued accreditation.
the creation of new programs through the application building process including serving as the initial program support during the application and accreditation phase.
all action plans documented related to duty hours are transparent to all involved to eliminate the risk of further violations.
as a key resource for organizing and analyzing departmental data to identify trends monitor compliance and support data-driven decision-making.
and Training
guidance and training to program directors coordinators residents and fellows on accreditation standards and requirements.
with Director Academic Affairs to ensure program coordinators are given proper initial and continued training.
program coordinators with processing house staff travel including review and processing of resident requests for conference travel and handling of reimbursements.
and maintain positive and supportive relationships with the OLOL GME Programs and affiliated GME programs.
with special projects and duties as assigned by the Director of Academic Affairs and the Designated Institutional Officer.
all GMEC Executive subcommittee meetings and special called meetings including notices location food arrangements attendance tracking and detailed minutes.
aware of onboarding credentialing and employment file processes for new incoming Residents and Fellows and communicate any changes in regulation requirements to the onboarding team.
and ensure successful completion of all current Resident and Fellow advancement and distribution and collection of renewing annual Resident and Fellow Contracts.

Minimum Required Education:Bachelors Degree required in Education Healthcare or Business Administration Nursing Allied Health or related field.

Minimum Experience: 5 years of work experience in a healthcare or academic setting.