Accreditation Coordinator

The University of Kansas Hospital; Bell (CA); On-site; USD 60,000 - 90,000; Full time

Job summary

The University of Kansas Hospital is seeking an Accreditation Coordinator to ensure ongoing compliance with The Joint Commission (TJC) and CMS standards. You will monitor standards, coordinate activities, and support internal audits to drive quality and safety across the organization.

Responsibilities include data analysis, in-person tracers, and developing corrective action plans in collaboration with clinical teams.

Qualifications

• Bachelor's degree in Nursing, Respiratory Care, or related clinical field; or Master's degree if Bachelor's is non-clinical.
• Minimum 2+ years healthcare experience (hospital, ambulatory, or clinical setting).
• Strong communication and analytical skills with ability to develop corrective action plans and contribute to regulatory readiness.

Responsibilities

• Develops and maintains accreditation and regulatory readiness activities.
• Collects, analyzes and reports data for continuous readiness.
• Performs in-person tracers and medical record reviews to assess compliance.
• Disseminates audit results to leadership and stakeholders.
• Interprets standards in relation to policies and practice.
• Maintains knowledge of accreditation standards and provides education as needed.
• Leads quality improvement actions to achieve compliance.
• Acts as a Scribe for surveys by accrediting bodies and CMS.

Skills

Excellent communication

Organizational skills

Analytical skills

Interpersonal skills

Drive to off-site locations

Education

Bachelor's degree in Nursing/Respiratory Care or related clinical field

Master's degree in related field (acceptable if Bachelor's is non-clinical)

Tools

Spreadsheets & databases

Data analysis tools

Job description

Position Summary / Career Interest:

The Accreditation Coordinator plays a critical role in maintaining the organization's compliance with healthcare accrediting bodies such as The Joint Commission (TJC) and regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS). This position ensures continuous compliance and readiness for surveys by monitoring standards, coordinating accreditation activities, and facilitating internal audits. The coordinator participates in the development and implementation of corrective action plans, collaborates with clinical and administrative teams to address deficiencies, and promotes a culture of quality and safety throughout the hospital. Strong organizational, communication, and analytical skills are essential to drive accreditation excellence and adherence to standards.

Responsibilities and Essential Job Functions

• Develops and maintains accreditation and regulatory readiness activities to support safety and ongoing regulatory compliance.
• Collects, analyzes and reports data in support of continuous readiness activities.
• Performs in-person patient and departmental tracers and medical record review audits to assist in determining compliance with accreditation and regulatory requirements.
• Disseminates the results of audits and surveillance as needed and as data is available. Dissemination occurs via electronic communication, presentations at organization-wide venues, and directly with hospital leaders.
• Interprets standards in relation to policies and practice.
• Maintains knowledge and serves as a resource for interpretation of accreditation and disease-specific care certification standards as applicable. Provides formal and informal education on regulatory requirements as needed.
• Utilizes quality improvement techniques and tools, leads/assists in the development and implementation of detailed action plans to achieve compliance.
• Serves as a Scribe for all routine, unannounced, and for‑cause surveys by the accrediting organizations (such as TJC), CMS, KDHE, or other regulatory agencies.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelors Degree in Nursing , Respiratory Care, or other related clinical field OR
• Master's Degree in related field is acceptable if Bachelor's degree is non-clinical
• 2 or more years healthcare experience (hospital, ambulatory, or other clinical setting)

Preferred Licensure and Certification

• Licensed Registered Nurse (LRN) - Multi-State - State Board of Nursing
• Licensed Respiratory Therapist (RT) - State Board of Healing Arts
• Pharmacy Technician Registration - State Board of Pharmacy
• Licensed Social Worker(LBSW) - State Board of Behavioral Sciences

Knowledge Requirements

• Excellent communication, writing, organizational and presentation skills
• Advanced working knowledge of computer spreadsheets and databases.
• Strong interpersonal skills and ability to establish supportive and collaborative relationships
• Must be willing to drive to off-site locations.

Job Location

• Kansas City, Kansas, United States

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.