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Summary The primary purpose of the position is serves as a Health System Specialist, Accreditation Specialist, provides program oversight and coordination of all VACCHCS external review programs including, but not limited to: The Joint Commission (TJC), Office of Inspector General (OIG), Government Accountability Office (GAO), and collaborates with the Mental Health Program Lead on Commission on Accreditation of Rehabilitation Facilities (CARF) . Responsibilities Major duties include: Provides oversight of the accreditation programs at the medical center and associated CBOCs, and coordinates facility-wide survey readiness programs including annual training of survey readiness consultants and oversight of any facility wide contracts for accreditation training and survey readiness programs. Responsible for planning, organizing, directing, and monitoring the VACCHS Accreditation Program and ensures the program is carried out consistent with VHA requirements as well as those of external review organizations and accrediting bodies. Accountable for participation in facility-wide program strategic planning, establishment and continuity of standards, and quality management and operational implementation. Coordinates the implementation of policies, programs and procedures with the VISN affecting the facility accreditation programs. Responsible for keeping VISN and facility accreditation stakeholders current with any updates from accreditation internal and external offices or agencies. Conducts routine, ongoing, and as-needed analysis of external review data to identify improvement opportunities and presents this information in effective methods across the network. Work Schedule: Monday - Friday, 7:30am - 4:00pm Virtual: This is not a virtual position. Position Description Title/PD#: Health System Specialist/PD01607O Physical Requirements: The work is primarily sedentary, although some slight physical effort may be required. Work is typically performed in an adequately lighted and climate-controlled office. Travel may be required. Requirements Conditions of Employment You must be a U.S. citizen to apply for this job Subject to a background/suitability investigation Selective Service Registration is required for males born after 12/31/1959 A complete application package; Resume, Transcripts, etc. is required Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Upon completion of your probationary period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Qualifications To qualify for this position, applicants must meet all requirements by the closing date of this announcement. Health System Specialist Individual Occupation Requirements (IOR): Undergraduate and Graduate Education: Major study -- hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration. or Specialized Experience: Progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following: Missions, organizations, programs, and requirements of health care delivery systems; Regulations and standards of various regulatory and credentialing groups; and Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. Special Provision for In-service Placement: Successful completion of an agency-sponsored on-the-job training program may be substituted for qualifying experience, provided it included a formal individualized training plan. Such a training program must have been conducted in an operating health care system and included: Assignments providing a knowledge of basic health system administration philosophies, practices, and procedures, and basic government administrative policies and requirements; Practical assignments providing an opportunity to apply health system administration skills and principles (as the individual progresses, work assignments must be characteristic of the grade level to which he or she is assigned); and Oversight by an experienced health system administrator with periodic evaluation of the individual's progress and appropriate adjustment of the training program. In addition to the Individual Occupational Requirement candidates must also meet the following specialized experience and/or education: GS-11 grade level: One year of specialized experience (equivalent to the GS-09 grade level in the federal service); experience that equipped the applicant with the particular knowledge, skills and abilities (KSA's) and other characteristics to perform successfully the duties of the position, and that is typically in or related to the work of the position to be filled, in the normal line of progression for the occupation in the organization. Specialized experience includes: Directly related to the work of the position and has equipped you with the particular knowledge, skills and abilities to successfully perform the duties as a Health System Specialist. Qualifying specialized experience is defined as progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following: (1) Missions, organizations, programs, and requirements of health care delivery systems; (2) Regulations and standards of various regulatory and credentialing groups; and (3) Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. At this level, applicants would have obtained this experience working within a health care setting, working directly with clinicians and other administrators to solve problems in support of the delivery of patient care; and ensuring compliance with policy and directives related to accreditation programs. ~OR~ Education: Successfully completed a Ph.D., equivalent doctoral degree, three (3) full years of progressively higher level graduate education leading to such a degree, Or LL.M in the related field of the position to be filled (i.e., hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration). The education portion must include courses that demonstrate the knowledge, skills, and abilities necessary to do the work of this position. Education must have been obtained in an accredited college, or university. NOTE: Transcripts must be submitted with your application materials. Education cannot be credited without documentation. ~OR~ Applicants may also combine education and experience to qualify at the GS-11 level. Combinations of successfully completed graduate level education (beyond a master's degree) and specialized experience as described above to meet total experience requirements. The education portion must include graduate courses that demonstrate the knowledge, skills, and abilities necessary to do to the work of this position (i.e., hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration). NOTE: Transcripts must be submitted with your application materials. Education cannot be credited without documentation. Experience must be clearly indicated in your resume. To calculate, first identify the percentage of required education you have earned (when substituting, you cannot use the first 60 semester hours that you earned). Then identify the percentage of required experience you possess. Add the two percentages. The total percentage must equal at least 100 percent to qualify at the GS-11. For example, an applicant who has 9 semester hours of graduate level education (i.e. 50% of graduate education required) and 6 months of creditable specialized experience (i.e. 50% of the required experience) would equal 100% of the required experience for the position A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Education Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/.If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. Additional Information Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act. A supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced VA competitive service employees with selection priority over other candidates for competitive service vacancies. To be well-qualified, applicants must possess experience that exceeds the minimum qualifications of the position including all selective factors if applicable, and must be proficient in most of the requirements of the job. Information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website which can be found at https://www.opm.gov/. Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. This job opportunity announcement may be used to fill additional vacancies. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.