Clinical Manager Quality & Accreditations

Description

The ASC Accreditations & Quality Manager to oversee the quality and accreditations for our ambulatory surgery centers (ASCs). The ASC Clinical Manager Quality & Accreditations will ensure our ambulatory surgery centers meet the required standards of quality and safety, work in collaboration with site Administrators to implement standards from accreditation bodies including The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), and support Administrators in maintaining facility standards in accordance with all regulatory requirements and accreditation standards.

This position will develop quality dashboards for both internal and external customers. The ASC Accreditations & Quality Manager will sit on MEC and quality committees for all of IBJI’s ASCs.

• Ensure adherence to regulatory standards (state, federal, and accreditation bodies like JCAHO, AAAHC, and CMS), staying updated on changes and adapting practices accordingly.
• Lead the preparation process for accreditation surveys, ensuring the facility is ready to demonstrate compliance with standards.
• Serve as the point of contact for communication with accreditation bodies and maintain accurate records of policies, procedures and other documentation required for accreditation.
• Actively participates in all ASC Medical Executive, Quality committees and any other appropriate committees relevant to the role.
• Partners with the Corporate Manager of Payer Relations to ensure quality data for third party administrators is timely.
• Develops, implements, evaluates, and enforces facility policies and procedures, goals, and objectives.
• Develops, implements, and evaluates methods to ensure effective and efficient use of staff, facilities, equipment, and other resources while maintaining patient care standards.
• Develop, implement, and oversee quality improvement programs to ensure the highest quality patient care.
• Develops, implements, and coordinates quality management, utilization review, and discharge planning programs.
• Directs the preparation and maintenance of patients' clinical records.
• Collect, analyze, and interpret data from various sources (e.g. patient records, feedback, risk assessments) to identify areas for improvement. Prepare reports on quality improvement activities and organizational performance.
• Consults with nurse managers and medical staff on patient care or nursing problems and interpretation of facility policies to ensure patient needs are met.
• Visits departments to observe procedures and make appropriate suggestions and recommendations for improving techniques, policies, and procedures.
• Participate in the development and modifications of facility programs.
• Participates in infection control and quality assessment activities and analysis.
• Provide education and training to staff on accreditation standards and requirements, and improved care protocols.
• Identify and evaluate existing processes, develop recommendations to address concerns, and implement new initiatives to enhance patient safety and quality of care.
• Design and execute training programs for staff on quality improvement and risk management protocols.
• Work collaboratively with various departments, including nursing, physicians, and administrative teams, to establish facility-wide goals and promote quality improvement initiatives.
• Perform reviews of clinical care practices.
• Analyze patient feedback and healthcare facility records.
• Implement and promote new healthcare initiatives.
• Other duties as assigned.

• Partners with Administrators to help direct care in nursing/clinical areas.
• Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws.

• Requires BS degree in Nursing, from an accredited nursing school, with current RN license. Master degree preferred.
• Clinical management experience and/or training; or equivalent combination of education and experience will be considered.

• Certifications in healthcare quality (e.g Certified Professional in Healthcare Quality (CPHQ)) and change management are preferred.

• Minimum 10 years experience in the healthcare field.
• Progressive leadership experience in an ASC or hospital setting, possess expert-level knowledge of the accreditation standards, management of a multidisciplinary clinical team, and understanding of nursing practice and working with surgeon customers.
• Experience with national healthcare…