Clarification from the agency

This vacancy is open to current permanent Veterans Affairs Employees and CTAP eligibles.

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Duties include but are not limited to:

• Provide support to the facility's by assisting in the assessment, development, implementation, coordination and evaluation.
• Develop and implements tools that measure the hospital's compliance to the privacy incidents/complaints and HIPAA standards.
• Maintain compliance files and library. Performs a variety of typing using word processing equipment, databases, and spreadsheet software to record, revise, correct, merge, print and program material
• Conducts Facility Site Assessment (FSA) - quarterly reports (consolidating Privacy, Records Management, Freedom of Information Act (FOIA), Facility Complexity, and Privacy Research).
• Establishes and implements reporting processes for the appropriate accounting of all disclosures of privacy protected information made by the facility.
• Ensure the appropriate utilization of the Release of Information (ROI) Records Management software by the facility ROI Department and other areas making disclosures of patient health information.
• Prepare and address the identified pre-review documentation requests, and/or are specific and complete in response to post-review response questions or action items.
• Analyzes TJC Accreditation Survey, PCA, FSA, PSETS and any other related measurement data using the appropriate statistical process control techniques and tools.
• Collects and summarizes data; identifies opportunities for improvement and presents findings on a monthly basis to appropriate committees.
• Ensures methods and procedures are carried out in conformance with regulations and higher headquarters directives.
• Reviews and initiates action and provides guidance to staff members pertaining to compliance issue
• Performs other related duties as assigned.

Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level.

Work Schedule: Monday - Friday, 8:00 am - 4:30 pm, (Subject to change based on the needs of the Agency)
Telework: This position may be authorized for telework. Telework eligibility will be discussed during the interview process.
Virtual: This is not a virtual position.
Position Description/PD#: Government Information Specialist/PD033050 and PD033080
Relocation/Recruitment Incentives: Not Authorized
Critical Skills Incentive (CSI): Not Authorized
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

• You must be a U.S. Citizen to apply for this job
• To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the job.
• Selective Service Registration is required for males born after 12/31/1959
• Physical Requirements: Work is sedentary. It requires sitting, walking, bending and carrying light items such as books, papers and files. The work required does not inherently include any physical requirements essential for successful job performance that could not otherwise be performed with accommodation or workplace adjustment. A pre-placement physical examination is not required.
• Subject to background/security investigation
• 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.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP)

As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period or 2-year trial 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.

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.

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 09/17/2026.

Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement.

• For a GS 9 position you must have served 52 weeks at the GS 7.
• For a GS 11 you must have served 52 weeks at the GS 9.

The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade.

Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment.

You may qualify based on your experience and/or education as described below: For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

GS 9 Level: You may qualify based on your experience and/or education as described below:

• Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Communicate effectively in writing to prepare administrative correspondence, technical documents, analytical studies, formal directives, user manuals and regulations/policies. Communicate effectively orally to advise and give recommendations on TJC guidance for the employees at all levels (to include agency level). Utilize a personal computer and software such as word processors, graphics, spreadsheets, database management systems or communications to produce a wide range of documents (e.g., reports, memorandums, letters, etc.), incorporate data from different software applications and update databases or spreadsheets.

OR,

• Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have a master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D., if related; transcripts required.

OR,

• Combination: Applicants may also combine education and experience to qualify at this level. You must have an combination of specialized experience and graduate education which totals in excess of one year or 18 credit hours; transcripts required.

GS 11 Level: You may qualify based on your experience and/or education as described below:

• Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS 9 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Utilize a wide range of principles, concepts and methodologies related to healthcare quality and system management. Develop objectives, determine priorities and demonstrate the ability to meet those objectives. Utilize analytical and program evaluation skills to assess problems and to provide consultation and assistance with key personnel to enhance effectiveness, promote innovation and resolve deficiencies. Apply Privacy Freedom of Information Act programs, The Joint Commission (TJC) standards, Patient Safety Program, quality improvement theories, risk management principles, total quality management, utilization management, statistical tools, and economic analysis to conduct analyses and studies pertaining to TJC requirements, develop guidance and techniques for quality improvement and analyze and advise on proposed new directives. Apply VA and VHA regulations pertaining to TJC standards to include laws pertaining to the protection of quality improvement information.

OR

• Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have a Ph.D. or equivalent doctoral degree, or 3 full years of progressively higher level graduate education leading to such a degree, or LL.M, if related; transcripts required.

OR

• Combination: Applicants may also combine education and experience to qualify at this level. You must have an combination of specialized experience and graduate education which totals in excess of two years or 36 credit hours; transcripts required.

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following Competencies for this position:

• Communications
• Security
• Manages and Organizes Information

Your experience must be fully documented on your resume and must include job title, duties, month and year start/end dates AND hours worked per week. A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Overstating your qualifications and/or experience in your application materials or application questionnaire may result in your removal from consideration. Cheating on the online assessment may also result in your removal from consideration.

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.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.