Cancer Program Accreditation Coordinator

Full Time, 1st Shift, Monday-Friday

The Cancer Program Accreditation Coordinator is responsible for coordinating, monitoring, and supporting accreditation activities for the cancer service line, with primary oversight of the American College of Surgeons (ACoS) Commission on Cancer (CoC) accreditation program and support for National Accreditation Program for Breast Centers (NAPBC) accreditation efforts. This position ensures ongoing compliance with accreditation standards, promotes continuous readiness for surveys, facilitates quality improvement initiatives, and serves as a key resource for multidisciplinary teams involved in cancer care delivery.

Reporting to the Director of Cancer Services, the Accreditation Coordinator works collaboratively with physicians, cancer registry staff, nurse navigators, quality personnel, breast program leaders, imaging services, surgical services, pathology, genetics, and other stakeholders to support accreditation requirements and improve cancer care outcomes across the organization.

Key Responsibilities:

• Coordinate all activities related to maintaining Commission on Cancer (CoC) accreditation and supporting NAPBC accreditation efforts.
• Monitor and interpret CoC, NAPBC, and other applicable accreditation standards and communicate requirements to leadership and program stakeholders.
• Maintain continuous survey readiness through proactive monitoring, auditing, and compliance assessment activities.
• Serve as the primary coordinator for accreditation site visits, surveys, and mock surveys.
• Develop and maintain accreditation work plans, timelines, documentation, and evidence files required for surveys and annual reporting.
• Monitor cancer program compliance with accreditation standards and organizational policies.
• Conduct periodic audits and assessments to identify gaps in compliance and develop corrective action plans.
• Collaborate with clinical and operational leaders to implement performance improvement initiatives related to accreditation findings and cancer program quality measures.
• Track and report key quality indicators, accreditation metrics, and compliance outcomes.
• Assist in the development and implementation of policies, procedures, and workflows supporting accreditation standards.
• Other duties as assigned by the Director of Cancer Services

Qualifications:

• Bachelor's degree in healthcare administration, nursing, public health, health sciences, or a related healthcare field.
• Minimum of 3-5 years of healthcare experience, with experience in oncology, quality improvement, accreditation, regulatory compliance, cancer registry, program coordination, or performance improvement preferred.
• Demonstrated experience managing projects, regulatory requirements, accreditation standards, or quality initiatives.
• Strong analytical, organizational, and problem-solving skills with the ability to work independently and manage multiple priorities.
• Excellent written and verbal communication skills with the ability to collaborate effectively with physicians, leaders, and multidisciplinary teams.
• Proficient in Microsoft Office Suite, including Excel, PowerPoint, Word, and data reporting tools.

Preferred Qualifications

• Clinical credential (RN, RT(R), RRT, CTR, or other healthcare-related credential).
• Certified Tumor Registrar (CTR), Oncology Certified Nurse (OCN), Certified Professional in Healthcare Quality (CPHQ), or similar certification.
• Experience with Commission on Cancer (CoC), NAPBC, oncology quality programs, accreditation processes, or healthcare regulatory compliance.
• Experience with cancer registry operations, quality metrics, oncology program management, or performance improvement initiatives.