Accreditation Representative

1 week ago

Smithfield, United States UNC Health Full time

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:

Responsible for assuring compliance
with American College of Surgeon Commission on Cancer (ACS COC) Standards,
Surveillance, Epidemiology, and End Results Program (SEER) Regulation, and
other oncology related standards. This
position is also responsible for managing and assuring compliance of the
Low-Dose Lung Cancer Screening Program accreditation and assuring compliance
with the American College of Radiology Lung Cancer Screening Registry
(ACR-LCSR).

The Cancer Accreditation Specialist is
to facilitate and oversee all analytic and reporting tasks necessary to pass
the cancer program components of accreditation and the lung cancer screening
components of accreditation, including CMS reimbursement criteria for the
ACR-LCSR.

Responsibilities:
Ensures all American College of Surgeons (ACS) Commission on Cancer standards are met for accreditation. Leads survey prep at facility, completing the Program Application Record (PAR), Survey Application Record (SAR), and surveyor documentation.
Coordinates and facilitates all Cancer Committee Meetings to ensure each meeting supports CoC accreditation standards; including meeting schedules, agendas, attendance of required multidisciplinary members, minutes, and all documentation. Maintains documentation of Cancer Committee and cancer program activities. Assists with the completion of the Cancer Program's Annual Report.
Serves as the Cancer Conference/Tumor Board Coordinator and facilitates all Cancer Conferences/Tumor Boards; including scheduling, agendas, and documentation.
Monitors, evaluates, and analysis's all Cancer Conference/Tumor Board activities; including, attendance, case presentation, and ensuring staging and prognostic indicators are discussed. Attend state and national educational activities as approved by the Director. Participates in required continuing education programs.
Assists in developing and utilizing data gathering tools, such as surveys/questionnaires, work sampling, and database linkages to ensure that appropriate quantitative and qualitative data is gathered for the analysis. Assists in the development of project proposals, recommendations, implementation plans, communication packages, performance measurement tools, and training materials related to the cancer program.
Evaluates and distills analyses conducted by other departments, outside consultants, and/or programmers. Facilitate data extraction with the CTR for analysis and interpretation. Structures and executes analysis independently.
Manage the Low-Dose CT Lung Cancer Screening Program; including data collection, assessment category updates in EPIC, ensuring follow-up and result letters are completed. Enters data into the American College of Radiology NRDR Lung Cancer Screening Registry (LCSR). Ensures LungRADS assessments are entered correctly into the LCSR to meet CMS guidelines for reimbursement. Facilitates data extraction with the Chest Pain Coordinator of all Chest Pain data and inputs extracted data into the American College of Cardiology (ACC) Chest Pain database.
Prepares reports synthesizing analytical results, highlighting implications of findings. Recommends suggested action steps based on the analytic results, and reports to management.
Contributes to practice development and department administration including, recruiting, debriefing on training, and developing thought pieces on topics like change management. May provide input to performance reviews of others in department.

Other Information

Other information:
Education Requirements:
•Bachelor's degree in an appropriate discipline or equivalent.
Licensure/Certification Requirements:
Professional Experience Requirements:
•With a Bachelor's degree, no prior experience required.
•With an Associate's Degree, requires four (4) years of experience in quality team facilitation, project management, process improvement or quality data analysis.
•Experience in a department involved with the diagnosis and/or treatment of cancer preferred. Prior experience synthesizing and analyzing data and interpreting quantitative/qualitative analysis preferred. Experience with Microsoft Word, Excel, PowerPoint is strongly preferred.
Knowledge/Skills/and Abilities Requirements:

Job Details

Legal Employer: NCHEALTH

Entity: Johnston Health

Organization Unit: Accreditation

Work Type: Full Time

Standard Hours Per Week: 40.00

Salary Range: $18.20 - $25.86 per hour (Hiring Range)

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: US:NC:Smithfield

Exempt From Overtime: Exempt: No

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.

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