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 includes a Joint Commission-accredited tertiary care hospital, outpatient clinics, the Mile Square Health Center network of federally qualified health centers, and the seven UIC health science colleges: Applied Health Sciences, Dentistry, Medicine, Nursing, Pharmacy, Public Health, and Jane Addams College of Social Work. 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 supervises 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 improve the quality of care at UI Health.

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 data management.
• Assist with data collection, assessment, and compilation for annual and three-year Survey Application Records (SAR) for submission to accrediting bodies.
• Provide hospital-wide leadership for accreditation and regulatory readiness, developing and implementing readiness plans and follow-up actions.
• Assess organizational accreditation readiness and vulnerabilities, implementing continuous survey readiness plans.
• Perform cancer data collection to assist leaders in achieving organizational objectives.
• Participate in acquiring and sharing best practices 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 for case finding, abstracting, and follow-up using NCRA cancer coding principles.
• Serve as the system administrator for the Cancer Registry ERS System and ensure state reporting compliance.
• Collaborate with IT staff to integrate cancer registry data with clinical and administrative systems (e.g., OncoNav).
• Oversee clinical cancer performance, analyzing practice patterns, identifying areas for improvement, and implementing quality improvement initiatives.
• Develop assessment and reporting structures to ensure compliance with ACS CoC, NAPBC, and NAPRC standards.
• Coordinate quality activities 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 ASCO’s Quality Oncology Practice Initiative (QOPI).
• Serve as a resource for education and training on quality improvement, accreditation standards, and regulatory requirements (e.g., TJC, CMS, QOPI).
• Support clinical operations staff in practice analysis and improvement.
• Facilitate data collection and reporting for quality improvement activities.
• Participate in performance improvement initiatives using evidence-based approaches to patient safety and quality.
• Collaborate with the Sr. Director to provide input on budgetary requirements for the Tumor Registry Program.

Requirements

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