| Job Description: |
The Assistant Director of Accreditation provides operational leadership for the accreditation and continuous quality improvement functions of the University of Florida College of Medicine Graduate Medical Education (GME) Office. Reporting to the GME Director of Administration, this position manages a major segment of the institution's education and training operations and supports the oversight of ACGME-accredited residency and fellowship programs, including ACGME Non-Standard Training (NST) programs, within a large, complex academic medical center.
The Assistant Director serves as a institutional resource for accreditation standards, program review, policy implementation, and program improvement. The position translates accreditation requirements into practical guidance, coordinates institutional review and monitoring activities, supervises assigned professional and support staff, and partners with program directors, coordinators, faculty, and GME leadership to promote consistent and sustainable compliance. As part of the GME leadership team, the Assistant Director is cross-trained in the Director's core accreditation responsibilities and provides leadership continuity for assigned functions when delegated or during the Director's absence.
About This Role:
Accreditation Oversight and Program Consultation
- Direct day-to-day accreditation support and consultation for assigned GME programs and institutional functions.
- Interpret and apply ACGME Institutional, Common Program, and specialty-specific requirements; provide timely, consistent guidance to program directors, coordinators, faculty, and GME staff.
- Manage routine accreditation monitoring activities, including review of program letters, citations, Areas for Improvement, accreditation statuses, action plans, and required institutional follow-up.
- Monitor institutional compliance with Program Letters of Agreement (PLAs) and provide oversight of the PLA process, including review of status reports, identification and escalation of gaps or expired agreements, and verification that designated staff and programs complete required actions.
- Provide institutional support and operational oversight for ACGME NST programs, including interpretation of applicable requirements, ongoing compliance monitoring, and guidance to program and department leadership.
- Develop and maintain accreditation resources, templates, calendars, standard operating procedures, and communication tools that support consistent institutional practices.
- Identify emerging compliance risks, recommend corrective strategies, and escalate significant or systemic concerns to the Director, Associate DIO, and DIO as appropriate.
- Serve as a liaison between the GME Office, clinical departments, program leadership, and institutional stakeholders on assigned accreditation matters.
Program Review, Applications, and Site Visit Readiness
- Coordinates complex program review and accreditation-readiness activities from planning through follow-up.
- Coordinate institutional preparation for ACGME institutional and program site visits, focused reviews, self-studies, and other accreditation-related reviews.
- Review draft new program applications, complement increases, participating site additions, program changes, and related submissions for completeness, internal consistency, and alignment with institutional expectations.
- Assist with the development, institutional review, and submission of new ACGME NST program applications and renewals, and coordinate preparation for NST-related site visits, reviews, and required follow-up.
- Provide structured consultation to programs preparing responses to citations, requests for progress reports, adverse actions, or other ACGME communications.
- Conduct targeted audits of accreditation records and program documentation; track findings, responsible parties, deadlines, and completion of corrective actions.
- Maintain readiness materials and standardized processes that allow the GME Office to respond efficiently to planned and unplanned accreditation activity.
Committee Operations and Institutional Governance
- Lead or support GME committee processes that advance institutional oversight and regulatory compliance.
- Manage the operational work of assigned GMEC subcommittees, including agenda development, document review, presentation of findings, action tracking, and maintenance of an auditable record.
- Support the Accreditation Requirements Review Committee (ARRC) and other assigned committees; chair meetings or workgroups when delegated by the Director.
- Oversee the operational work of the NST Committee, including application review, agenda and meeting coordination, documentation of decisions, action tracking, and communication with programs and institutional leadership.
- Prepare accreditation analyses, recommendations, and decision materials for GMEC and GME leadership.
- Partner with the Director in developing, reviewing, and implementing institutional GME policies and procedures.
- Ensure assigned committee actions and approvals are completed within applicable institutional and ACGME timelines.
Data Monitoring and Continuous Quality Improvement
- Use institutional and program-level data to support early identification of risk and continuous program improvement.
- Monitor ACGME survey results, milestones, evaluation data, work hour information, accreditation trends, and other indicators for patterns requiring program or institutional action.
- Develop dashboards, reports, and concise leadership summaries that translate accreditation data into actionable recommendations.
- Support the Institutional Program Review Committee (IPRC), Annual Program Evaluation oversight, Special Review processes, and other institutional quality improvement activities.
- Establish performance measures for assigned accreditation functions and evaluate the timeliness, consistency, and effectiveness of processes.
- Collaborate with GME leadership, analysts, and institutional partners to improve data quality, reporting, documentation, and governance.
Education, Training, and Resource Development
- Design and deliver education that strengthens accreditation knowledge and operational consistency across the institution.
- Develop and deliver onboarding, workshops, written guidance, and continuing education for program directors, associate program directors, coordinators, faculty, and GME staff.
- Assess learning and resource needs and revise educational offerings based on accreditation changes, recurring findings, stakeholder feedback, and institutional priorities.
- Translate complex regulatory information into clear, practical tools and examples for varied audiences.
- Promote shared learning and dissemination of effective accreditation and program-management practices across programs.
Leadership, Supervision, and Operational Continuity
- Provide direct leadership for assigned staff and contributes to the strategic and operational management of the GME Office.
- Supervise assigned managers, professionals, and support staff; establish priorities, assign work, provide coaching, evaluate performance, and support professional development.
- Participate as a member of the GME management team and contribute to strategic planning for accreditation, education, and program quality functions.
- Manage special projects and cross-functional initiatives delegated by the Director, Associate DIO, or DIO.
- Maintain cross-training and working knowledge of the Director's core accreditation portfolio; assume delegated authority for defined functions and provide operational leadership during planned absences or leadership transitions.
- Represent the institution at regional or national GME accreditation meetings as delegated
- Foster a collaborative, service-oriented, accountable, and inclusive work environment.
We Offer Exceptional Benefits
- Low-cost State Health Plans: Medical, Dental, and Vision Insurance
- Life and Disability Insurance
- Generous Retirement Options to secure your future
- Comprehensive Paid Time Off Packages with 10+ paid holidays, paid family, sick and vacation leave
- Exceptional Personal and Professional Development Opportunities: Access to UF Training & Organizational Development programs, leadership development, LinkedIn Learning, and more
- Tuition Assistance through the UF Employee Education Program
- Public Service Loan Forgiveness (PSLF) Eligible Employer
Learn more about what we have to offer here!
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| Preferred: |
The ideal candidate will possess:
- Master's degree in education, health professions education, higher education administration, healthcare administration, public health, business administration, or a related field.
- Five or more years of progressively responsible experience in graduate medical education, academic medicine, accreditation, education administration, or a related regulatory environment.
- Demonstrated knowledge of ACGME Institutional, Common Program, and specialty-specific requirements and experience supporting program or institutional accreditation activities.
- Experience coordinating accreditation reviews, new program applications, site visits, Special Reviews, Annual Program Evaluations, or responses to accreditation findings.
- Supervisory or team-lead experience, including prioritizing work, coaching staff, and managing performance.
- Experience using a residency management system such as New Innovations and accreditation systems such as the ACGME Accreditation Data System.
- Experience analyzing educational or compliance data and developing reports, dashboards, presentations, or recommendations for leadership.
- Strong consultation, writing, presentation, project management, judgment, and relationship-building skills in a complex, decentralized organization.
- Ability to manage multiple high-priority deadlines, exercise discretion with sensitive information, and communicate regulatory expectations clearly and diplomatically.
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