Accreditation & Regulatory Affairs Specialist

Northwell Health

8h

About The Position

Manages Northwell's cancer care program accreditation processes, ensuring continuous compliance with standards set by the American College of Surgeons (ACS) Commission on Cancer (CoC) and the National Accreditation Program for Breast Centers (NAPBC). Leads accreditation efforts, facilitating committee meetings, preparing and submitting reports, collaborating with multidisciplinary teams, and driving quality improvement initiatives to maintain a culture of excellence in cancer care.

Requirements

• Bachelor's Degree required, or equivalent combination of education and related experience.
• 1–3 years of relevant experience in ACoS cancer accreditation required.
• Demonstrated expertise in CoC (Commission on Cancer) and NAPBC (National Accreditation Program for Breast Centers) accreditation standards, with the ability to anticipate regulatory updates and proactively adapt processes to maintain ongoing compliance highly preferred.
• Proven ability to collaborate with clinical and non-clinical staff and leadership to develop and implement effective strategies for continuous improvement and sustained compliance highly preferred.
• Flexibility to be onsite as needed highly preferred.

Responsibilities

• Oversee all aspects of the accreditation process for cancer care programs, including the American College of Surgeons (ACS) Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC), from initial assessment to ongoing compliance.
• Coordinate and facilitate committee meetings, adhering to ACoS CoC and NAPBC standards for composition, scheduling, agendas, and attendance.
• Lead the CoC survey process, including completion of the Pre-Review Questionnaire (PRQ) an all post-survey follow-up activities.
• Prepare and submit timely and accurate reports to accrediting bodies and internal leadership.
• Maintain comprehensive documentation for accreditation submissions and ongoing compliance.
• Collaborate with clinical and non-clinical staff and leadership to develop and implement effective strategies for continuous improvement and sustained compliance.
• Communicate effectively with all levels of the organization, including leadership, physicians, clinicians, and support staff, to promote understanding of and engagement in accreditation goals and objectives.
• Provide education and guidance to cancer program staff on accreditation standards, policies, and procedures.
• Proactively maintain in-depth knowledge of CoC and NAPBC accreditation standards, anticipating regulatory updates and adapting processes to ensure continued compliance.
• Analyze data related to patient outcomes and program performance to identify areas for improvement and inform for strategic decision-making.
• Assist with the development and implementation of action plans to address any deficiencies identified during audits or reviews.
• Work closely with clinical staff, administration, and external stakeholders to promote a culture of quality and compliance throughout the cancer center.
• Serve as a liaison between the cancer center and accrediting bodies, facilitating communication, and ensuring an effective relationship.
• Maintain accurate records of accreditation activities and outcomes.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees