Accreditation and Regulatory Specialist (Cancer Accreditation & Quality Manager)

University of Illinois Chicago•Chicago, IL

2d•Hybrid

About The Position

The Cancer Accreditation and Quality Manager will be responsible and accountable for planning, organizing and managing activities and programs related to cancer accreditation/regulatory readiness and quality initiatives. The Cancer Accreditation and Quality Manager conducts the hiring, training and education of the Tumor Registry staff. The Cancer Accreditation and Quality Manager works closely with the following individuals to support and improve the quality of University of Illinois Hospital and Clinics: Oncology Service Line Medical Director, Department Administrators and Coordinators, Senior Leaders within the Hospital & Health Sciences System, and Integrated Practice Unit Leaders.

Requirements

Bachelor's degree required in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science, or other discipline related to the Healthcare field.
Two (2) years (24 months) of work experience with the standards and survey process of an organization that includes accreditation.
Applicants possessing a Master's degree in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science or other discipline related to the Healthcare field meet the requirements of #1 above.

Nice To Haves

Experience with Commission On Cancer Accreditation Standards and Survey Process
Experience with Tumor Registry Data Abstraction

Responsibilities

Supervise accreditation functions for maintaining compliance with American College of Surgeons Commission on Cancer (ACS CoC) standards as well as National Accreditation Program for Breast Centers (NAPBC), National Accreditation Program for Rectal Cancers (NAPRC) and other accreditations to be determined (e.g. - National Committee for Quality Assurance-Patient Centered Specialty Practice).
Support activities to successfully meet the standards set by the accreditation programs, such as helping to prepare UI Health Hospital and Clinics for accreditation surveys, conducting medical record analysis, data abstraction and overall data management.
Assist with data collection, assessment and compilation for the annual and three-year Survey Application Records (SAR) for submission to the American College of Surgeons and other accreditation programs.
Provide hospital-wide leadership for accreditation and regulatory readiness program.
Lead the development and implementation of regulatory readiness plans and follow up actions.
Assess organizational accreditation readiness and vulnerabilities and implements continuous readiness survey plans.
Perform cancer data collection to assist leaders in accomplishing individual or organizational objectives.
Ongoing participation in acquiring best practice information and sharing with internal and external stakeholders.
Assist in the assessment, measurement and reporting of ongoing compliance with the CoC standards and other regulatory requirements.
Supervise the operations and planning for the cancer registry for UI health Hospital and Clinics.
Hire, train, and evaluate the certified and non-certified staff who perform case finding, abstracting and follow-up utilizing approved National cancer registrars’ association (NCRA) cancer coding principles for Commission on Cancer (CoC) Accreditation standards; responsible for the Cancer Committee at UI Health Hospital and Clinics.
Serve as the system administrator for the Cancer Registry ERS System; responsible for State Reporting.
Work with IT staff from UIH and Oncology Service Line to provide cancer registry data for linkage to tumor registry specific information systems (i.e. OncoNav) and other clinical and administrative information systems.
Oversight of clinical cancer performance in analyzing current practice patterns, identifying areas for improvement and developing methods to help implement and evaluate improvement changes.
Develop an ongoing assessment and reporting structure to ensure quality study and improvement compliance with ACS CoC and NAPBC, NAPRC.
Coordination of the execution of quality activities, which may include process, structure, and/or outcomes across the Cancer Integrated Practice Unit or individual tumor sites (e.g. - Breast, Prostate, Lung, Colorectal, Head & Neck, etc.).
Supervise initial assessment, participation requirements, and on-going compliance in an external quality improvement /initiative offered by a cancer related organization, such as American Society of Clinical Oncology's Quality Oncology Practice Initiative (QOPI).
Serve as a resource for education and training regarding quality improvement, accreditation standards, internal process improvements, and external regulatory requirements. (e.g.-TJC, CMS, QOPI, etc.).
Serve as a resource and provide support to clinical operations clinicians and staff in the areas of practice analysis and improvement.
Provide facilitation, data collection and reporting of quality improvement activities.
Participate in ongoing performance improvement activities and initiatives.
Execute evidence-based approaches to patient safety and quality improvement.
In collaboration with Sr. Director, provide input to budgetary requirements for Tumor Registry Program.