Accreditation Coordinator

The University of Kansas Health System; Kansas City (MO); On-site; USD 65,000 - 90,000; Full time

Job summary

The University of Kansas Health System is seeking an Accreditation Coordinator to lead and/or assist in system-wide activities to evaluate and improve adherence to TJC accreditation standards and CMS CoPs. The role focuses on readiness for accreditation surveys and regulatory investigations to ensure safe patient care.

Responsibilities include data collection and reporting, conducting tracers, maintaining information databases, and supporting OPPE/FPPE processes.

Qualifications

• Bachelor's Degree in Health Information Management or related field.
• Experience with data management and reporting.
• Strong written and verbal communication.

Responsibilities

• Assist in ensuring accuracy and timeliness in submissions to reporting centers.
• Collect, analyze and report data in support of readiness activities.
• Conduct patient and system tracers in care areas to observe practice.
• Disseminate audit results and surveillance findings as needed.
• Interpret relevance of standards to hospital policies and practices.
• Maintain databases for quality initiatives and regulatory mandates.
• Perform concurrent and closed medical record review audits for compliance.
• Provide data for OPPE/FPPE to Medical Staff Service as requested.
• Serve as a resource for interpretation of regulatory and accreditation standards.

Skills

Communication skills

Data analysis

Time management

Education

Bachelor's Degree in Health Information Management

Bachelor's degree in Nursing, Respiratory Care or Clinical Laboratory Science

High School Diploma

Master’s Degree (preferred)

Tools

Microsoft Excel

Microsoft Word

Microsoft Access

Job description

Position Title

Accreditation Coordinator

Days - Full Time

Bell Hospital

Position Summary / Career Interest:

The Accreditation Coordinator leads and/or assists the Manager in system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs), including ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery ofsafe patient care.

Responsibilities and Essential Job Functions

• Assist in assuring accuracy and timeliness in submission to reporting centers ( i.e. Sterling Readiness Rounds)
• Collects, analyzes and reports data in support of continuous readiness activities
• Conducts patient and system tracers in patient care areas through observation of practice
• Disseminates the results of audits and surveillance as needed and as data is available
• Interpretation of relevance of standards in relation to hospital and clinic policies and practice
• Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates
• Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements
• Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to Medical Staff Service as requested
• Serve as a resource for interpretation of regulatory, accreditation and disease‑specific care certification standards (as applicable)
• 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 Health Information Management from an accredited College or University OR
• Bachelors in Nursing, Respiratory Care or Clinical Laboratory Science
• High School Graduate

Preferred Education and Experience

• Master’s Degree from an accredited College or University

Knowledge Requirements

• Excellent communication, writing, organizational and presentation skills; demonstrates superior oral and written communication and time management skills
• Advanced working knowledge of computer spreadsheets and databases.
• Must have strong knowledge base of Microsoft Excel, Word, and prefer experience with data management, ie Microsoft Access.
• Must be willing to drive to off‑site hospital locations.

Time Type:

Full time

Important information for you to know as you apply:

• The health system is an equal employment opportunity employer. Qualified applicants are considered for employment without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, ancestry, age, disability, veteran status, genetic information, or any other legally‑protected status. See also Diversity, Equity & Inclusion.

• The health system provides reasonable accommodations to qualified individuals with disabilities. If you need to request reasonable accommodations for your disability as you navigate the recruitment process, please let our recruiters know by requesting an Accommodation Request form using this link [e-mail].

• Employment with the health system is contingent upon, among other things, agreeing to the health-system-dispute-resolution-program.pdf and signing the agreement to the DRP.