The University of Kansas Hospital - Accreditation & Education Careers

Accreditation Coordinator Job

Facility: The University of Kansas Hospital - Main Campus


Schedule: Full Time

Shift: Days

Hours: 40

The University of Kansas Hospital's mission is "To Lead the Nation in Caring, Healing, Teaching and Learning." We are committed to hiring individuals who demonstrate both a strong fit with our team-based and patient-focused culture and who have the skills, knowledge, and experience to succeed in their chosen position. Individuals selected for employment are those who will help us advance our mission and who exemplify our values through their personal and professional actions.

We currently have an opening for an Accreditation Coordinator.

The Accreditation Coordinator is responsible for leading and/or assisting the Manager in system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs). This includes ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery of safe patient care.


Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable).

Interpretation of relevance of standards in relation to hospital and clinic policies and practices.

Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements.

Conducts patient and system tracers in patient care areas through observation of practice.

Collects, analyzes and reports data in support of continuous readiness activities.

Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to Medical Staff Services as requested.

Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates.

Disseminates the results of audits and surveillance results as needed and as data is available.

Assist in assuring accuracy and timeliness in submission to reporting centers (i.e. Sterling Readiness Rounds).

Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.


Bachelor's Degree in Health Information Management, Nursing, Respiratory Care, or Clinical Laboratory Science.

Excellent communication, writing, organizational and presentation skills. Demonstrates superior oral and written communication, organization, and time-management skills.

Advanced working knowledge of computer spreadsheets and databases. Must have strong knowledge base of Microsoft Excel, Word, and prefer experience with database management, ie Microsoft Access.

Must be willing to drive to off-site hospital locations.

Previous experience in regulatory compliance or quality improvement is strongly preferred.

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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.