Accreditation Coordinator

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. 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. #J-18808-Ljbffr The University of Kansas Health System