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Manager, Cancer Accreditation & Education

Department: Oncology
Reports To: System Director of Clinical Service Lines
FLSA Status: Exempt

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Position Summary

The Manager, Cancer Accreditation & Education is responsible for leading all cancer program accreditation activities and educational initiatives across the health system. This role oversees compliance with the American College of Surgeons Commission on Cancer (ACS CoC) standards, Joint Commission, HFAP, and Illinois Department of Public Health (IDPH) requirements. The Manager ensures continuous survey readiness, manages the tumor registry program, coordinates multidisciplinary cancer committees and tumor boards, and develops staff education and competency programs that support exceptional oncology patient care.

This position serves as a key liaison between oncology leadership, physicians, regulatory agencies, and interdisciplinary teams to maintain accreditation standards, improve program performance, and foster a culture of continuous learning and quality improvement.

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Essential ResponsibilitiesCancer Accreditation & Regulatory Compliance

• Lead all activities related to obtaining, maintaining, and renewing ACS Commission on Cancer (CoC) accreditation for multiple campuses.
• Ensure compliance with Joint Commission, HFAP, IDPH, and other regulatory requirements.
• Coordinate accreditation surveys, including preparation, documentation review, logistics, and surveyor interactions.
• Serve as the primary point of contact during accreditation and regulatory site visits.
• Develop, manage, and monitor accreditation work plans, ensuring timely completion of required activities.
• Conduct routine audits and compliance rounds across oncology and infusion service locations.
• Identify regulatory risks and implement corrective action plans to maintain survey readiness.

Oncology Program Management

• Oversee Tumor Registry operations, ensuring data integrity, quality, and compliance with reporting standards.
• Directly supervise Tumor Registry personnel, including performance management, scheduling, staffing, payroll, and professional development.
• Monitor cancer program metrics and utilize data to support quality improvement initiatives.
• Maintain documentation and reporting requirements for cancer program accreditation standards.

Education & Staff Development

• Assess learning needs and develop educational programs that support organizational goals and regulatory requirements.
• Design, implement, and evaluate training programs utilizing adult learning principles and evidence-based instructional methods.
• Provide annual competencies, education, and skills validation for oncology and infusion staff.
• Develop educational materials, reference guides, and performance support tools.
• Facilitate multidisciplinary educational sessions, workshops, and seminars.
• Incorporate current research, best practices, and industry standards into educational programming.

Tumor Board & Committee Coordination

• Manage tumor board operations across all campuses.
• Ensure timely scheduling, attendance tracking, documentation, meeting minutes, and case presentation compliance.
• Coordinate Cancer Committee meetings and support compliance with CoC standards.
• Maintain records and reports required for accreditation and quality initiatives.

Leadership & Collaboration

• Partner with physicians, nursing leadership, operational leaders, and clinical staff to achieve oncology program goals.
• Communicate accreditation status, risks, and improvement opportunities to leadership.
• Participate in strategic planning, performance improvement projects, and interdisciplinary workgroups.
• Provide operational leadership support and backup coverage for oncology management as needed.
• Promote a culture of accountability, collaboration, innovation, and patient-centered care.

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QualificationsEducation

• Master's degree in Healthcare Administration, Nursing, Education, Public Health, Organizational Development, or a related field required.
• Equivalent combination of education and experience may be considered.

Experience

• Minimum of 10 years of experience in healthcare education, staff development, oncology program management, accreditation, or related healthcare leadership roles.
• Experience managing cancer program accreditation and regulatory compliance required.
• Previous supervisory or management experience preferred.

Knowledge, Skills, and Abilities

• Extensive knowledge of ACS Commission on Cancer standards and accreditation processes.
• Strong understanding of Joint Commission, HFAP, and IDPH regulatory requirements.
• Expertise in curriculum development, instructional design, adult learning principles, and competency assessment.
• Demonstrated experience leading multidisciplinary teams and managing complex projects.
• Strong analytical, organizational, problem-solving, and decision-making skills.
• Excellent verbal, written, presentation, and facilitation skills.
• Proficiency in Microsoft Office Suite and healthcare information systems.
• Ability to manage multiple priorities while meeting deadlines in a fast-paced environment.

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Preferred Certifications

• Oncology Certified Nurse (OCN) preferred.
• Certified Healthcare Accreditation Professional (CHAP) or similar accreditation certification preferred.
• Certified Tumor Registrar (CTR) knowledge or experience preferred.
• Leadership, education, or project management certification preferred.

 

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Core Competencies

• Leadership & Team Development
• Regulatory Compliance & Accreditation
• Quality Improvement & Patient Safety
• Communication & Collaboration
• Customer Service Excellence
• Strategic Planning & Execution
• Performance Improvement
• Professional Accountability
• Diversity, Equity & Inclusion
• Change Management & Organizational Development

This position plays a critical leadership role in ensuring excellence in oncology care through regulatory compliance, accreditation success, staff education, and continuous quality improvement.