Specialty Quality & Accreditation Coordinator

Overview

Performance Planning

 

Reporting to the Assistant Director of Pharmacy Outpatient Services, the Specialty Quality & Accreditation Coordinator is responsible for managing and maintaining the pharmacy's compliance with URAC and ACHC accreditation standards. This position serves as the primary administrative lead for accreditation readiness, quality reporting, and data management. The Coordinator will independently run and analyze operational reports, manage the accreditation dashboard, conduct patient chart audits, and support strategic pharmacy initiatives. This role bridges health administration expertise and pharmacy operations to ensure continuous compliance, operational excellence, and business growth.

 

Responsibilities

Key Responsibilities/Essential Functions

 

 

Accreditation & Quality Management

• Serve as the primary administrative lead for URAC and ACHC accreditation maintenance and renewal processes.
• Manage and maintain the accreditation compliance dashboard and shared folder, ensuring all required documentation is current, organized, and audit-ready at all times.
• Run, compile, and analyze reports for quarterly Quality Management Committee (QMC) meetings; prepare QMC notes, scorecards, and annual quality summaries.
• Ensure pharmacy policies and procedures are updated, formatted, and aligned with current URAC and ACHC accreditation standards and TherigySTM workflows.
• Manage annual compliance requirements including fire drills, hazard training, business continuity testing, and communication materials.
• Coordinate accreditation timelines, track deliverable deadlines, and maintain documentation to ensure the pharmacy is continuously survey-ready between accreditation cycles.

Clinical & Operational URAC & ACHC Auditing

• Conduct routine patient chart audits to ensure compliance with URAC and ACHC clinical documentation standards and accreditation requirements.
• Retrieve and verify external provider notes and clinical assessments to confirm they are completed within appropriate timeframes.
• Verify and document temperature and humidity monitoring logs.
• Complete daily insurance audits and monitor outstanding claims to support revenue cycle integrity.
• Assist with annual 340B audits, including auditing of 340B prescriptions sent to contract pharmacies.
• Track incident/accident reports, patient complaints, and other quality-related issues; ensure timely documentation and follow-up.
• Ensure Human Resources maintains all necessary audit documentation, including annual staff license verifications.

Quality & Operational Improvement

• Monitor day-to-day adherence to policies and procedures by Medication Access Specialists and other pharmacy support staff; escalate identified gaps or concerns to the Assistant Director.
• Identify workflow inefficiencies and propose process improvements using quality improvement methodologies.
• Ensure pharmacy staff have completed yearly competency training and maintain documentation of compliance.
• Maintain patient-facing materials including handbooks, educational pamphlets, and the pharmacy website.
• Manage communication and compliance logs in alignment with accreditation standards.

Strategic Project Support

• Support the planning and execution of strategic pharmacy initiatives.
• Pull, organize, and analyze operational data to support leadership decisions.
• Coordinate with external vendors, consultants, and accreditation bodies to track deliverables and maintain project timelines.
• Prepare data summaries, presentations, and reports. 

General Support

• Provide administrative and analytical support to the Assistant Director of Outpatient Pharmacy Services for ongoing and new strategic initiatives.
• Other duties as assigned to support departmental goals and operational efficiency.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Qualifications

Minimum Knowledge, Skills, Experience Required

 

Registration/Certification: 

Active Alabama Pharmacy Technician registration required within 6 months of hire. National PTCB or ExCPT certification is required within 6 months of hire.

 

Education: 

Bachelor's degree in Health Administration, Business Administration, Public Health, or a related field required. Master's degree (MHA, MBA, MPH, MPA) strongly preferred.

 

Required: 

Minimum of one year of experience in healthcare administration, quality management, data analysis, or pharmacy operations. Experience with URAC/ACHC accreditation standards preferred.

Preferred: 3+ years of pharmacy practice experience.

Technical: Proficient in Microsoft Office, pharmacy equipment, and pharmacology (medication classes).

Professional: Strong interpersonal, telephone, and communication skills.

Execution: Detail-oriented with a focus on follow-up and the ability to meet deadlines under pressure.

 

Must be able to read, write legibly, speak, and comprehend English.

 

Working Conditions

 

Able to stand, walk, reach, sit, crouch and stoop for extended periods of time.  Must be able to carry objects weighing 35 pounds.  Requires good motor coordination with good manual and finger dexterity.  Must have the ability to communicate with staff and patients of all ages.  Physical presence onsite is essential.  Hearing and vision must be normal or corrected to within normal range.  Able to perform the duties with or without reasonable accommodation.