Clinical Manager Quality & Accreditations

About the role

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.

Responsibilities

• 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