Job Description
Accreditation and Regulatory Specialist (Cancer Accreditation & Quality Manager)
Hiring Department Oncology Service Line
Location Chicago, IL USA
Requisition ID 1042137
FTE 1
Work Schedule Monday-Friday
Shift Days
# of Positions 1
Workplace Type Hybrid
Posting Close Date August 21st, 2026
Salary Range (commensurate with experience): $83,886.40 - 169,915.00 / Annual Salary
About the University of Illinois Hospital & Health Sciences System (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 and 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. Learn more: https://hospital.uillinois.edu/about-ui-health
This position is intended to be eligible for benefits This includes Health, Dental, Vision, Life Insurance, a Retirement Plan, Paid time Off, and Tuition waivers for employees and dependents.
The Cancer Accreditation and Quality Manager will be responsible and accountable for planning, organizing and managing activities and programs related to cancer accreditation/regulatory readiness and quality initiatives. The Cancer Accreditation and Quality Manager conducts the hiring, training and education of the Tumor Registry staff. The Cancer Accreditation and Quality Manager works closely with the following individuals to support and improve the quality of University of Illinois Hospital and Clinics:
- Oncology Service Line Medical Director
- Department Administrators and Coordinators
- Senior Leaders within the Hospital & Health Sciences System
- Integrated Practice Unit Leaders
Duties & Responsibilities
- Supervise accreditation functions for maintaining compliance with American College of Surgeons Commission on Cancer (ACS CoC) standards as well as National Accreditation Program for Breast Centers (NAPBC), National Accreditation Program for Rectal Cancers (NAPRC) and other accreditations to be determined (e.g. - National Committee for Quality Assurance-Patient Centered Specialty Practice).
- Support activities to successfully meet the standards set by the accreditation programs, such as helping to prepare UI Health Hospital and Clinics for accreditation surveys, conducting medical record analysis, data abstraction and overall data management. Assist with data collection, assessment and compilation for the annual and three-year Survey Application Records (SAR) for submission to the American College of Surgeons and other accreditation programs.
- Provide hospital-wide leadership for accreditation and regulatory readiness program.
- Lead the development and implementation of regulatory readiness plans and follow up actions. Assess organizational accreditation readiness and vulnerabilities and implements continuous readiness survey plans.
- Perform cancer data collection to assist leaders in accomplishing individual or organizational objectives.
- Ongoing participation in acquiring best practice information and sharing with internal and external stakeholders.
- Assist in the assessment, measurement and reporting of ongoing compliance with the CoC standards and other regulatory requirements.
- Supervise the operations and planning for the cancer registry for UI health Hospital and Clinics
- Hire, train, and evaluate the certified and non-certified staff who perform case finding, abstracting and follow-up utilizing approved National cancer registrars’ association (NCRA) cancer coding principles for Commission on Cancer (CoC) Accreditation standards; responsible for the Cancer Committee at UI Health Hospital and Clinics .
- Serve as the system administrator for the Cancer Registry ERS System; responsible for State Reporting. Work with IT staff from UIH and Oncology Service Line to provide cancer registry data for linkage to tumor registry specific information systems (i.e. OncoNav) and other clinical and administrative information systems.
- Oversight of clinical cancer performance in analyzing current practice patterns, identifying areas for improvement and developing methods to help implement and evaluate improvement changes. Develop an ongoing assessment and reporting structure to ensure quality study and improvement compliance with ACS CoC and NAPBC, NAPRC
- Coordination of the execution of quality activities, which may include process, structure, and/or outcomes across the Cancer Integrated Practice Unit or individual tumor sites (e.g. - Breast, Prostate, Lung, Colorectal, Head & Neck, etc.)
- Supervise initial assessment, participation requirements, and on-going compliance in an external quality improvement /initiative offered by a cancer related organization, such as American Society of Clinical Oncology's Quality Oncology Practice Initiative (QOPI).
- Serve as a resource for education and training regarding quality improvement, accreditation standards, internal process improvements, and external regulatory requirements. (e.g.-TJC, CMS, QOPI, etc.)
- Serve as a resource and provide support to clinical operations clinicians and staff in the areas of practice analysis and improvement
- Provide facilitation, data collection and reporting of quality improvement activities
- Participate in ongoing performance improvement activities and initiatives.
- Execute evidence-based approaches to patient safety and quality improvement.
- In collaboration with Sr. Director, provide input to budgetary requirements for Tumor Registry Program
Minimum Qualifications
- Bachelor's degree required in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science, or other discipline related to the Healthcare field.
- Two (2) years (24 months) of work experience with the standards and survey process of an organization that includes accreditation.
**Applicants possessing a Master's degree in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science or other discipline related to the Healthcare field meet the requirements of #1 above.
Preferred Qualifications
- Experience with Commission On Cancer Accreditation Standards and Survey Process
- Experience with Tumor Registry Data Abstraction
To Apply: For fullest consideration click on the Apply Now button, please fully complete all sections of the online
application including adding your full work history with specific details of your duties & responsibilities for each position held. Fully complete the education, licensure, certification and language sections. You may upload a resume, cover letter, certifications, licensures, transcripts and diplomas within the application.
Please note that once you have submitted your application you will not be able to make any changes. In order to revise your application you must withdraw and reapply. You will not be able to reapply after the posting close date. Please ensure the application is fully completed and all supporting documents have been uploaded before the posting close date.
Illinois Residency is required within 180 days of employment.
The University of Illinois System is an equal opportunity employer, including but not limited to disability and/or veteran status, and complies with all applicable state and federal employment mandates. Please visit Required Employment Notices and Posters to view our non-discrimination statement and find additional information about required background checks, sexual harassment/misconduct disclosures, and employment eligibility review through E-Verify.
The university provides accommodations to applicants and employees. Request an Accommodation
Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.
