GME Accreditation and Data Management Specialist

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Work Shift

Day (United States of America)

Job Summary:

Under the direction of the Graduate Medical Education (GME) leadership, the GME Accreditation and Data Mgmt. Specialist provides administrative support for the compliance of graduate medical education training programs at WHS. Duties include planning, coordinating, and implementing processes and procedures to ensure compliance with accreditation requirements, new innovations reporting, and CMS reporting.

Core Responsibilities and Essential Functions:

GME Accreditation Duties Learn and maintain a strong knowledge base of Accreditation Council for Graduate Medical Education (ACGME) and other accrediting body requirements and regulations. Provide administrative support to Graduate Medical Education (GME) in facilitating the coordination and monitoring of Clinical Learning Environment Review (CLER) visits, Annual Institutional Reviews, Annual Program Evaluations and Annual Program updates through WebADS. Develop and maintain project management tools to support programs in continued preparation and management of portfolio reviews, evaluations, program evaluations, etc. Assist the Program Coordinators and Program Directors as needed in the preparation of documentation for Graduate Medical Education Committee (GMEC) and ACGME deadlines. Prepare Self-Study visits, Site Visit documentation, surveys (Resident & Faculty), Internal & Special Reviews and Annual Program Reviews Maintain knowledge of the rules, regulations, policies, administrative guidelines, and legal issues that impact or govern the residency programs and ensures that Creighton University is in compliance Interpret and apply ACGME and other national accrediting agencies requirements, and hospital policies to support compliance Assist with accreditation planning and applications for new programs Monitor and disseminate information regarding various institutional and program accreditation Create document controls and standardization for resident and fellow notifications (corrective action, etc.) Coordinate GMEC meetings, including scheduling, agendas, and minutes transcription and reporting of the meetings Facilitate the National Residency Matching Program (NRMP) match activation and approval process, track program change requests Facilitate the Grievance/Appeals process Ensure program compliance with various accreditation reporting Assist preparation of data collection for the ACGME Annual Institutional Review (AIR) Report and additional reports and presentations for the Dean's Office and Board of Directors Serves as the liaison between GME and the ACGME, AAMC, AMA (FREIDA,) NRMP, and other organizations, assuring that each Program meets deadlines and provides correct information Tracks, reports and ensures compliance with procedures regarding licensing, moonlighting, annual contracts, and initial and re-credentialing of trainees Facilitates the development and tracking of institutional GME level policies Facilitates the creation of quick guides and tools that will support mentoring and development of new and existing program coordinators Supports GME leadership with special projects and other duties as needed Data Mgmt. Duties Oversee all operational aspects of the New Innovations database and medical education related data systems. Data collection and accuracy for reporting to internal and external stakeholders. Manage & collaborate with site partners on financial cost reporting related to the Intern and Resident Information System (IRIS). Expert resource for New Innovations system providing training to residents, fellows, coordinators, and faculty. Create tutorials/manuals and conduct database workshops for GME program personnel. Provide training sessions and assist staff in consistency & use of data collection systems. Design common database protocols for GME administration for scholarly activity, conferences, evaluations, milestone reporting and other required program activities. Prepare required data for the annual reports and audits. Work with the GME Manager, DIO, and Residency Program Directors to provide required data to the Accreditation Council of Graduate Medical Education (ACGME) including but not limited to the Annual Institutional Report, Program Evaluation Committee and Clinical Competency Committee. Prepare monthly, semi-annual, and annual dashboards required for graduate medical education programs. Collect and analyze data and perform process improvement opportunities. Participates on or leads initiatives to design and implement recommendations, including areas such as regulatory compliance, reporting data collection and quality improvement. Collaborate with GME Coordinator to track, report, and ensure compliance with procedures regarding licensing, moonlighting, leaves of absence, annual contracts, and initial and re-credentialing of trainees. Collaborate with Contracts Coordinator to ensure up to date program letters of agreement with external sites. Participate in the residency recruitment process, intern orientation and graduation. Oversee file retention and historical data accuracy. Manage document and data integrity for GME process documents. Provide analytics support to the GME Manager, DIO, and Executive Director. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelors Health Administration or Masters Health Administration-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 2 years Experience in GME program coordination preferred; Experience in accreditation preferred Preferred

Required Minimum Skills:

Excellent written and verbal communcation with the ability to work in computer-based systems for data analytics. High Knowledge of the basic principles of ACGME and CMS GME guidelines. High Ability to multi-task, prioritize, organize, and meet deadlines. High Must be detail oriented. High

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