Accreditation and Regulatory Specialist (Cancer Accreditation & Quality Manager)

Location: Chicago, IL USA • Hybrid workplace • Full-time, Monday–Friday, days

About UI Health

The University of Illinois Hospital & Health Sciences System (UI Health) provides comprehensive care, education, and research to the people of Illinois and beyond. A part of the University of Illinois Chicago (UIC), UI Health comprises a clinical enterprise that includes a Joint Commission-accredited tertiary care hospital, outpatient clinics, and the Mile Square Health Center network of federally qualified health centers. It also includes the seven UIC health science colleges: the College of Applied Health Sciences; the College of Dentistry; the School of Public Health; the Jane Addams College of Social Work; and the Colleges of Medicine, Pharmacy, and Nursing, including regional campuses in Peoria, Quad Cities, Rockford, Springfield, and Urbana. UI Health is dedicated to the pursuit of health equity.

About the role

The Cancer Accreditation and Quality Manager is responsible for planning, organizing, and managing activities and programs related to cancer accreditation, regulatory readiness, and quality initiatives. This role conducts the hiring, training, and education of Tumor Registry staff and collaborates with the Oncology Service Line Medical Director, Department Administrators, Senior Leaders, and Integrated Practice Unit Leaders to support and improve the quality of care at University of Illinois Hospital and Clinics.

Responsibilities

• Supervise accreditation functions to maintain compliance with American College of Surgeons Commission on Cancer (ACS CoC) standards, National Accreditation Program for Breast Centers (NAPBC), National Accreditation Program for Rectal Cancers (NAPRC), and other accreditations (e.g., NCQA-Patient Centered Specialty Practice).
• Support activities to meet accreditation standards, including preparing for surveys, conducting medical record analysis, data abstraction, and overall data management.
• Assist with data collection, assessment, and compilation for annual and three-year Survey Application Records (SAR) for submission to accreditation programs.
• Provide hospital-wide leadership for accreditation and regulatory readiness, including developing and implementing readiness plans and follow-up actions.
• Assess organizational accreditation readiness and vulnerabilities, and implement continuous readiness survey plans.
• Perform cancer data collection to assist leaders in accomplishing organizational objectives.
• Participate in acquiring best practice information and sharing it with internal and external stakeholders.
• Assess, measure, and report ongoing compliance with CoC standards and other regulatory requirements.
• Supervise operations and planning for the cancer registry, including hiring, training, and evaluating certified and non-certified staff.
• Serve as the system administrator for the Cancer Registry ERS System and ensure state reporting compliance.
• Work with IT staff to provide cancer registry data for linkage to tumor registry-specific information systems (e.g., OncoNav) and other clinical/administrative systems.
• Oversee clinical cancer performance, analyzing practice patterns, identifying areas for improvement, and developing methods to implement and evaluate changes.
• Develop an ongoing assessment and reporting structure to ensure compliance with ACS CoC, NAPBC, and NAPRC quality standards.
• Coordinate quality activities, including process, structure, and outcomes across the Cancer Integrated Practice Unit or individual tumor sites (e.g., Breast, Prostate, Lung, Colorectal, Head & Neck).
• Supervise participation in external quality improvement initiatives, such as the American Society of Clinical Oncology's Quality Oncology Practice Initiative (QOPI).
• Serve as a resource for education and training on quality improvement, accreditation standards, internal process improvements, and external regulatory requirements (e.g., TJC, CMS, QOPI).
• Provide support to clinical operations clinicians and staff in practice analysis and improvement.
• Facilitate, collect, and report data for quality improvement activities.
• Participate in ongoing performance improvement activities and initiatives using evidence-based approaches to patient safety and quality improvement.
• Collaborate with the Senior Director to provide input on budgetary requirements for the Tumor Registry Program.

Requirements

• Bachelor’s degree in Nursing, Public Health, Business Administration, Business, Health or Operations Information Management, Environmental or Natural Science, or a related healthcare field.
• Two (2) years of work experience with the standards and survey process of an accreditation organization.
• A Master’s degree in the above fields may substitute for the required work experience.

Preferred Qualifications

• Experience with Commission on Cancer Accreditation Standards and Survey Process.
• Experience with Tumor Registry Data Abstraction.

Benefits

• Health, Dental, and Vision Insurance
• Life Insurance
• Retirement Plan
• Paid Time Off
• Tuition waivers for employees and dependents

Pay

$83,886.40 – $169,915.00 per year