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This job is HYBRID. There will be some opportunity to work from home, but most of the work will be onsite at FH Main Campus.

FTE: 1.000000

Shift: Shift 1

Monday – Friday with flexible start and end times.

Job Summary:

The Coordinator 1) organizes and coordinates quality and regulatory activities, including Joint Commission, DNV, and Centers for Medicare and Medicaid Services, to support continuous readiness across the organization, collaborating with multidisciplinary teams to ensure overall regulatory and accreditation compliance; 2) assists with the development and implementation of quality improvement processes, projects, and risk assessments; and 3) provides education and resources to stakeholders on quality, regulatory, and accreditation processes, standards, and measures.

This position will be focused on coordinating the Foundation for the Accreditation of Cellular Therapy (FACT) accreditation within our Blood & Marrow Transplant & Cellular Therapy program. The scope of this accreditation crosses the multiple organizations that comprise the MCW’s joint pediatric-adult BMT program (a collaboration of the Froedtert Hospital, Medical College of Wisconsin, Children’s Wisconsin, and Versiti) and this role would lead, facilitate and support the improvement of clinical and service quality in the BMT and Cellular Therapy program across all four organizations. Responsible for continuous program readiness and inspection, program quality improvement, maintenance of program policies, and overall accreditation activities.


Five years of clinical and/or clinical health care management experience is required. Clinical chart review, observation of work environments/processes or other data collection techniques is desired.


Baccalaureate Degree in Nursing or health-related field is required. Baccalaureate in Nursing is preferred. Master’s Degree in a Healthcare or related business field is preferred.


Knowledge of accreditation and regulatory requirements, including TJC, DNV, and CMS. Excellent verbal and written communication skills. Presentation skills. Able to facilitate meetings. Interpersonal skills to collaborate with leaders/departments to develop, monitor, and maintain improvement strategies for compliance. Organizational skills to manage multiple projects. PC proficiency to include Word, Excel and PowerPoint.


Prefer current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact).

Perks & Benefits at Froedtert Health

Froedtert Health Offers a variety of perks & benefits to staff, depending on your role you may be eligible for the following:

  • Paid time off
  • Growth opportunity- Career Pathways & Career Tuition Assistance, CEU opportunities
  • Academic Partnership with the Medical College of Wisconsin
  • Referral bonuses
  • Retirement plan – 403b
  • Medical, Dental, Vision, Life Insurance, Short & Long Term Disability, Free Workplace Clinics
  • Employee Assistance Programs, Adoption Assistance, Healthy Contributions, Care@Work, Moving Assistance, Discounts on gym memberships, travel and other work life benefits available

The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin’s only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce. We welcome protected veterans to share their priority consideration status with us at 262-439-1961. We maintain a drug-free workplace and perform pre-employment substance abuse testing. During your application and interview process, if you have a need that requires an accommodation, please contact us at 262-439-1961. We will attempt to fulfill all reasonable accommodation requests.


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