Position Summary / Career Interest:

The Specialty Pharmacy Accreditation Coordinator plays a key role within the Retail and Specialty Pharmacy Department, supporting the Assistant Director of Specialty Pharmacy in ensuring compliance with all specialty pharmacy accreditation standards. This position is responsible for maintaining accreditation readiness and overseeing compliance with regulatory bodies, including The Joint Commission (TJC), Accreditation Commission for Health Care (ACHC), and Utilization Review Accreditation Commission (URAC). Key responsibilities include implementing updates to accreditation standards, managing renewal processes, and ensuring continuous adherence to accreditation requirements. Preferred candidate will have experience with ACHC, URAC and/or TJC specialty pharmacy accreditation.

Responsibilities and Essential Job Functions

• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• Demonstrates the ability to lead quality improvement teams and transform data into information by coaching stakeholders to develop operational/clinical frame projects for analytical exploration, facilitating implementation of action plans to meet identified areas of opportunity, and identifying areas for strategic opportunity based on data analysis.
• Participates in clinical, quality, and operational meetings to discuss/communicate trends and data analysis to service line/department leadership. Develops collaborative relationships with physicians and leadership team members to disseminate data at an organizational level.
• Assists with implementation of ongoing organizational needs assessment for quality, regulatory compliance, accreditation, and certification activities to ensure that all service line/department sites are in compliance with required standards, including, but not limited to, the development and implementation of TJC tracer teams to continuously evaluate standards compliance and works with departments to maintain continuous readiness. Makes appropriate recommendations based on assessment.
• Develops and applies basic and intermediate statistical and analytical methodologies to qualitative and quantitative datasets in order identify data trends and opportunities for quality and performance improvement within the service line/department, including the interpretation and presentation of counterintuitive and/or controversial data.
• Demonstrates competence to selecting, utilizing, and training data analytic software and platform functions.
• Oversee data collection, abstraction, documentation, and monitoring from clinical and administrative sources to facilitate the delivery of safe and high quality integrated health care within the service line/department, including using the scientific method to design and implement data collection ensure concepts such as accuracy of data, inter-rater reliability, and minimize confounding variables.
• Collaborates with Quality Improvement Coordinator I and II to facilitate accuracy, timeliness, reproducibility, and confidentiality of data collection and reporting.
• Develops, monitors, and maintains dashboards, scorecards, and compliance reports utilizing advanced visualization techniques and data analytics that monitor quality, patient safety, regulatory preparedness outcomes, including, but not limited to blood culture contamination, hand hygiene, falls, critical results monitoring, billing/volume data, patient satisfaction CMS quality programs, Commission on Cancer, TJC, Quality Oncology Practice Initiative, and Vizient performance metrics; and other service line/department as needed.
• Serves as a subject matter expert (SME)/resource for clinical, quality, and performance improvement indicators within service line/department and ensures that data are interpreted accurately according to best practice and standard work procedures.
• Leads LEAN workshops as needed and participates in project development, facilitation, implementation, and sustainability of LEAN activities.
• Works collaboratively with internal partners, such as Risk Management, Organizational Improvement, Infection Control, and Kaizen Promotion Office
• Maintains competency and enhances professional growth and development though continuing education, conference attendance, workshops, and seminars, including  identifying opportunities for dissemination of salient quality and performance improvement outcomes professionally via publication or at conferences
• 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

• High School Graduate
• Bachelors Degree in Nursing Business, IT or other related
• Master's Degree MHSA, MBA, Nursing Organizational Leadership, Public Health, Informatics or other related field or equivalent experience

Preferred Education and Experience

• 2 or more years Healthcare experience
• Experience/working knowledge with database management tools (i.e. Microsoft Access, RedCap, Minitab, Visio, or other electronic data capture systems
• Experience with Adobe Professional

Preferred Licensure and Certification

• Certified Professional in Healthcare Quality (CPHQ) - National Association of Healthcare Quality (NAHQ)

Required Language Skills

• Fluent English - Read, write, and speak English

Knowledge Requirements

• Intermediate computer skills in Microsoft Word, Excel, Powerpoint
• Ability to effectively interact with multidisciplinary teams, including physicians, administrative staff, clinical personnel, peers, and patients
• Demonstrate persistence in solving problems
• Travel between UKHS sites/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.