Accreditation Coordinator

The University of Kansas Health System; Kansas City (KS); Sur place; USD 70 000 - 90 000; Plein temps

Résumé du poste

The University of Kansas Health System is seeking an Accreditation Coordinator to lead compliance with TJC, CMS, and related agencies. You will coordinate readiness activities, audits, and corrective actions while partnering with clinical and administrative teams to foster safety and quality.

Responsibilities include data collection and analysis, in-person tracers, and dissemination of findings to leaders. Strong communication and organizational skills are essential for success in this role.

Qualifications

• Bachelor's degree in Nursing, Respiratory Care, or related clinical field (or Master's if Bachelor's is non-clinical)
• 2+ years healthcare experience in hospital, ambulatory, or clinical setting
• Strong communication, writing, organizational and presentation skills
• Advanced working knowledge of computer spreadsheets and databases

Responsabilités

• 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 and surveillance results to leaders and stakeholders.
• Interprets accreditation standards and interprets policies and practice accordingly.
• Provides education on regulatory requirements and quality improvement plans.
• Acts as a Scribe for surveys by accrediting bodies (TJC), CMS, KDHE, etc.
• Supports drive to improve safety and quality across departments.

Connaissances

Communication

Writing

Organizational skills

Presentation skills

Interpersonal skills

Data analysis

Formation

Bachelor's degree in Nursing or related clinical field

Master's degree in related field (optional)

Outils

Spreadsheets

Databases

Microsoft Excel

Description du poste

Position TitleAccreditation CoordinatorDays - Full TimeBell HospitalPosition 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 FunctionsDevelops 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 ExperienceBachelors Degree in Nursing , Respiratory Care, or other related clinical field ORMaster's Degree in related field is acceptable if Bachelor's degree is non-clinical2 or more years healthcare experience (hospital, ambulatory, or other clinical setting)Preferred Licensure and CertificationLicensed Registered Nurse (LRN) - Multi-State - State Board of NursingLicensed Respiratory Therapist (RT) - State Board of Healing ArtsPharmacy Technician Registration - State Board of PharmacyLicensed Social Worker(LBSW) - State Board of Behavioral SciencesKnowledge RequirementsExcellent communication, writing, organizational and presentation skillsAdvanced working knowledge of computer spreadsheets and databases.Strong interpersonal skills and ability to establish supportive and collaborative relationshipsMust be willing to drive to off-site locations.Time Type:Full timeJob Requisition ID:R-57798Important 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.Need help finding the right job?We can recommend jobs specifically for you! Create a custom Job Alert by selecting criteria that suit your career interests.