This position follows a hybrid work model, requiring onsite presence approximately 40% of the time, which typically averages to two days per week.
This highly collaborative role serves as an institutional subject matter expert for Graduate Medical Education (GME) accreditation, compliance, and continuous process improvement. The position requires deep, working knowledge of Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements, Common Program Requirements, and related regulatory standards, with the ability to translate complex requirements into operationally effective policies, workflows, and tools.
The role exercises a high degree of initiative, independent judgment, and accountability in supporting the Sponsoring Institution's accreditation status and institutional oversight responsibilities. The Institutional Specialist works closely with the Manager, Accreditation and Compliance, Program Directors, and Program Coordinators to strengthen systems, harmonize policies, improve processes, and ensure a positive and compliant learning environment for residents and fellows.
This position also serves as the Training Program Liaison (TPL) for visa-holding trainees, leads GMEC administration, acts as a New Innovations superuser, and plays a central role in the development, maintenance, and implementation of the House Staff Manual.
Essential Functions
Accreditation, Evaluation & Institutional Oversight
Serves as an institutional expert on ACGME accreditation and compliance, with deep working knowledge of ACGME Institutional Requirements, Common Program Requirements, and specialty program standards.
Maintains current knowledge of accreditation and regulatory requirements from the ACGME.
Collaborates closely with the Manager, Accreditation and Compliance and GMEC Chair to support the Sponsoring Institution's accreditation status and continuous compliance.
Interprets and analyzes institutional, common, and specialty-specific requirements and advises leadership on compliance risks, improvement opportunities, and required actions.
Develops and maintains institutional compliance systems, tracking tools, and dashboards to monitor outcomes and ensure ongoing accreditation readiness.
Trainee Evaluation & Graduation Documentation
Provides institutional oversight and guidance for semi-annual, summative, and final evaluations, ensuring alignment with ACGME and institutional requirements.
Guides programs on all ACGME-required documentation for graduating residents and fellows, including final evaluations, Milestones reporting, and verification of completion of training.
Partners with Program Directors and Coordinators to establish standardized, reliable processes and timelines for evaluation completion, documentation accuracy, and record retention.
Reviews evaluation data and documentation trends to identify compliance gaps, risk areas, and opportunities for institutional and program-level improvement.
Advises programs on appropriate use of evaluation tools and documentation standards within New Innovations and other GME systems.
Program Coordinator Support, Partnership & Operations
Works collaboratively with Program and Institutional Coordinators to assess, standardize, and improve GME workflows, documentation practices, and operational processes.
Provides direct support to Institutional Coordinators, with a working and applied understanding of all Institutional Coordinator responsibilities.
Serves as a functional backup and escalation resource to ensure continuity of operations and compliance during staffing transitions, vacancies, or increased workload.
Acts as a trusted advisor and coach, providing guidance on accreditation expectations, documentation standards, institutional processes, and operational best practices.
Supports onboarding and ongoing development of new Program and Institutional Coordinators.
Process Improvement & Standardization
Analyzes institutional GME data longitudinally, including ACGME Resident/Fellow and Faculty Survey results, to monitor educational quality, identify trends, and provide early warning of potential non-compliance with ACGME accreditation requirements.
Synthesizes survey and institutional data to inform leadership, support GMEC oversight, guide targeted interventions, and drive continuous quality improvement.
Leads institutional efforts to standardize processes related to evaluations, trainee completion documentation, accreditation tracking, and coordinator workflows.
Designs and implements process improvement initiatives to reduce administrative burden, increase consistency across programs, and strengthen compliance infrastructure.
Develops tools, templates, and guidance materials to support consistent and effective implementation of institutional requirements.
Leads the ongoing update, harmonization, and maintenance of standards of work for the Institutional Compliance Team, ensuring workflows, documentation, and practices are aligned with Office of Medical Education practices.
Evaluates existing standards of work for gaps or inefficiencies and implements updates to promote consistency, clarity of roles, and sustainable compliance across the GME enterprise.
Policy Development & Harmonization
Supports the development, revision, and harmonization of GME institutional policies and procedures to ensure regulatory and accreditation alignment.
Provides expert interpretation of institutional policies to residents, fellows, and program leadership.
Plays a central role in the development, maintenance, and annual review of the House Staff Manual, ensuring accuracy, clarity, and alignment with accreditation standards.
Accreditation Documentation & Site Visit Readiness
Oversees review of ACGME documentation for institutional and program accreditation, including ADS entries, correspondence, and supporting materials.
Develops institutional systems and timelines for site visit preparation and supports programs in producing clear, accurate, and complete submissions.
Graduate Medical Education Committee (GMEC) Management
Manages the administration and operations of GMEC, including meeting coordination, agenda development, documentation, action item tracking, and follow-up.
Supports GMEC in fulfilling ACGME-mandated institutional oversight responsibilities, including review of policies, program evaluations, and significant program changes.
Maintains GMEC records to ensure regulatory compliance and institutional transparency.
Training Program Liaison & Visa Oversight
Serves as the institution's designated Training Program Liaison (TPL) for visa-holding residents and fellows.
Ensures institutional and trainee compliance with federal regulations governing the J-1 Exchange Visitor Sponsorship Program.
Manages the sponsorship, renewal, and documentation process and serves as liaison with ECFMG, legal counsel, and the resident and fellow upline.
Provides guidance to programs and trainees on visa compliance requirements and institutional responsibilities.
Provides institutional oversight for Non-Standard Training (NST) pursuant to ACGME NST Recognition, supporting clinical training for foreign national physicians in advanced subspecialty areas for which no ACGME accreditation or ABMS member board certification exists.
Oversees institutional eligibility, application, approval, tracking, and documentation of NST activities; ensures compliance with ACGME Institutional Requirements, ECFMG policies, and J-1 Exchange Visitor regulations; advises program and institutional leadership on NST supervision, evaluation, duration, funding, and reporting requirements; and maintains institutional records in support of ACGME NST Recognition.
Systems, Innovation & Leadership
Acts as a New Innovations superuser, serving as a resource for system configuration, reporting, optimization, and user support.
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