Accreditation and Compliance Manager

Accreditation and Compliance Manager

Job Summary

The position manages 115+ Graduate Medical Education (GME) physician training programs at the University of Colorado School of Medicine to maintain accreditation through the Accreditation Council for Graduate Medical Education (ACGME). This includes overseeing the delivery of high-quality educational programming and clinical training activities that meet all regulatory requirements established by the ACGME and its specialty and subspecialty Review Committees (RCs).

This role provides leadership and oversight of the GME Accreditation and Compliance team, which consists of institutional accreditation and compliance program managers and professionals who serve as subject matter experts on ACGME institutional and program-level requirements. The team collaborates closely with training programs to ensure ongoing regulatory compliance across all residency and fellowship programs.

The position is also responsible for advising physician program directors on effective educational strategies and methodologies to support continued accreditation. In addition to accredited programs, the role provides oversight for 100+ non-ACGME-accredited GME fellowship programs.

Furthermore, the position ensures consistent, accurate, and timely communication with key stakeholders, including program coordinators, program directors, department chairs, teaching faculty, and residents and fellows.

This position is critical to the success of the Graduate Medical Education program at the University of Colorado, providing strategic leadership to the team, guiding stakeholders and ensuring oversight of processes, data, innovation and compliance with ACGME.

Key Responsibilities

Accreditation and Compliance Team Supervision & Leadership (20%)

• Serve as liaison and leadership representative to internal and external entities when GME accreditation expertise is needed.
• Hire Accreditation and Compliance staff and oversee the onboarding and training of team members to ensure they are properly trained and equipped to successfully complete assigned job duties.
• Provide direct supervision to three (3) or more full-time exempt professionals.
• Ensure effective communication and exceptional customer service from the team to faculty, staff, residents, fellows, and stakeholders both internal and external to the university.
• Handle workload assignments, performance management, coaching and counseling, and leave management for direct reports.
• Review existing processes to identify opportunities for increased efficiency and effectiveness.
• Identify opportunities for innovation, including utilizing technology to reduce administrative burden.
• Collaborate with GME Director for Operations and Strategy to identify and improve workflows that cross operational and accreditation functions.
• Institutional Awards: Coordinate annual institutional Program Director and Program Coordinator Excellence Award process.
• Participate in GME long-range and short-term strategic planning.

ACGME Program Accreditation and Compliance - New Program and Site Visit Preparation (15%)

• 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.
• 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.

ACGME Program Accreditation and Compliance - Ongoing Education and Maintenance of Standards (20%)

• Educate program directors and coordinators on their specialty-specific and institutional ACGME requirements.
• Program Director & Coordinator Education: Lead organization of semi-annual half-day GME Essentials orientation for new program directors and associate program directors.
• 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 and at the institutional level
• Ensure that programs provide current information to ACGME within regulatory guidelines and deadlines through a formal annual Accreditation Data System (ADS) Annual Update, and on an ongoing basis throughout the year, as required.
• Develop and maintain expertise in continuously evolving regulatory requirements including ACGME Common, Specialty-specific Program Requirements and Institutional Requirements.

Institutional-Level ACGME Compliance (15%)

• Oversee Accreditation and Compliance data and reporting
• 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 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 ADS update to ACGME.

Monitoring of Underperforming Programs (15%)

• 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.

Non-ACGME-Accredited Program Oversight (10%)

• 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 ~110 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.

Special Projects (5 %)

• Special projects: Perform a variety of special projects to support departmental, institutional, and ACGME initiatives, such as FTE data collection, assistance with GME Leadership Retreat planning and execution, orientation and onboarding and other projects as assigned.

Work Location

Hybrid - this role is eligible for a hybrid schedule of 3 days per week on campus and as needed for in-person meetings.

Why Join Us

We have AMAZING benefits and offer exceptional amounts of holiday, vacation and sick leave! The University of Colorado offers an excellent benefits package including:

• Medical: Multiple plan options
• Dental: Multiple plan options
• Additional Insurance: Disability, Life, Vision
• Retirement 401(a) Plan: Employer contributes 10% of your gross pay
• Paid Time Off: Accruals over the year
• Vacation Days: 22/year (maximum accrual 352 hours)
• Sick Days: 15/year (unlimited maximum accrual)
• Holiday Days: 15/year
• Tuition Benefit: Employees have access to this benefit on all CU campuses
• ECO Pass: Reduced rate RTD Bus and light rail service

There are many additional perks & programs with the CU Advantage.

Qualifications

Minimum Qualifications

• 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 accreditation, program management, project management and of the total years of experience, 1-2 years of which must have included direct management of full-time equivalent professional staff.

Applicants must meet minimum qualifications at the time of hire.

Preferred Qualifications

• Master'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.
• Professional experience in Graduate Medical Education in an academic institution with responsibility for program administration and accreditation.

Knowledge, Skills and Abilities

• 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)