Description

Under limited direction, the Quality/Accreditation Specialist II plans, organizes, and maintains processes to ensure organizational compliance with cancer accreditation standards and to support continuous survey readiness. This role serves as an internal consultant to leaders, physicians, and multidisciplinary teams by interpreting accreditation and regulatory requirements, assessing compliance, and guiding operational implementation.

In addition to general regulatory responsibilities, this position supports specialized accreditation efforts within the Cancer Service Line, serving as a subject matter expert for cancer-related accreditation programs such as those established by the American College of Surgeons (e.g., INCP, NAPBC, NAPRC, and related programs). The Specialist leads and coordinates cancer accreditation activities across multiple sites and specialties, including documentation management, survey preparation, corrective action planning, and ongoing compliance monitoring.

The Specialist collaborates closely with clinical, administrative, quality, registry, and physician stakeholders in a highly matrixed environment, often leading through influence rather than direct authority. Responsibilities include facilitating required cancer accreditation committees, preparing and presenting standards-based materials, tracking performance and reporting requirements, and ensuring alignment of policies, governance structures, and workflows with accreditation standards.

This role also partners with management and staff to develop performance improvement initiatives as needed and interprets new or evolving regulations for education and implementation. The position requires broad, multidisciplinary experience, strong organizational skills, and the ability to manage complex, high-volume accreditation requirements while supporting quality, safety, and patient-centered outcomes across the organization.

GENERAL SUMMARY:

Under limited direction the Quality/Accreditation Specialist II,

• Plans, organizes and maintains a process to ensure organizational compliance with regulatory standards and continuous survey readiness.
• Serves as an internal consultant for the interpretation of standards and functional measurement of compliance.
• Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts.

Requirements

• Bachelor’s degree healthcare related field required.
• Master’s degree in health care field preferred.
• Minimum 5 years healthcare experience required; clinical/operational experience preferred.
• Demonstrated knowledge of CoC accreditations required and familiarity with other accrediting, licensing and regulatory standards desirable.
• Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and/or deep, experience within one service line, value stream, etc.).
• Experience presenting to departmental, product line, and business unit leadership.
• Knowledge of current healthcare issues and trends.