Clinical Manager Quality & Accreditations

Illinois Bone & Joint Institute; Illinois; Hybrid; USD 125,000 - 150,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k with company match

Paid holidays

Paid time off

Job summary

Illinois Bone & Joint Institute seeks an ASC Accreditations & Quality Manager to oversee quality and accreditation across IBJI’s ambulatory surgery centers. This role ensures compliance with Joint Commission, AAAHC, and CMS standards and leads quality improvement initiatives.

Will develop dashboards and participate in MEC and quality committees. The position requires a BSN with RN license, a Master’s degree preferred, and at least 10 years in healthcare with ASC/hospital leadership experience.

Qualifications

• BSN with current RN license; Master's degree preferred.
• Minimum 10 years in healthcare with progressive leadership in ASC or hospital settings.
• Expert knowledge of accreditation standards (JCAHO, AAAHC) and risk management.
• Experience with national healthcare databases (NSQIP, ASC QC, Leapfrog).
• Experience in quality, accreditation, and risk management is required.

Responsibilities

• Ensure compliance with state, federal, and accreditation standards.
• Lead preparation for accreditation surveys and demonstrate readiness.
• Maintain records of policies and accreditation documentation.
• Participate in ASC Medical Executive and Quality committees.
• Develop and monitor quality improvement programs and dashboards.
• Collaborate with nursing staff, physicians, and admins to drive quality initiatives.

Skills

Regulatory compliance

Communication skills

Leadership

Quality improvement

Data interpretation

Education

BSN and RN license

Master's degree (preferred)

Tools

Google Suite

Microsoft Office

NSQIP

ASC QC

Leapfrog standards

Job description

Description

Job Type

Full-time

Location

This is a remote position, but candidates must reside in Illinois. Regular onsite visits to our corporate office and various Ambulatory Surgery Center (ASC) locations are required.

Summary

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 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.

Supervisory Responsibilities

• 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.

Education

• 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/Licensure

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

Experience

• 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 databases such as NSQIP, ASC QC, Leapfrog, etc. required.
• Experience in quality, accreditation, and risk management is required.
• Experience in both Joint Commission and AAAHC standards
• Ambulatory Surgery Center experience preferred.

Technical Skills

• Experience with Google Suite and Microsoft Office preferred.
• In-depth understanding of healthcare quality improvement tools, techniques, and methodologies. Knowledge of healthcare regulations and standards
• The job requires computer skills. Must be adept at using various applications including database, spreadsheet, project management, graphics, word processing, communication by e-mail and use of specialty software.
• Ability to define problems, collect data, establish facts and draw valid conclusions.
• Evidence of continued education in clinical nursing and universal precautions.

Soft Skills

• Ability to effectively communicate (verbal and written) and present information.
• Understanding and commitment to the mission, values, and philosophy of the organization.
• Ability to set priorities.
• Superior interpersonal skills.
• Understanding and commitment to the mission, values, and philosophy of organization.
• Ability to work well with physicians, employees, patients and others.
• Ability to function effectively in stressful situations.
• Ability and willingness to adjust schedule to meet the needs of facility.
• Ability to work under supervision as well as ability to oversee others.

Physical Requirements

• While performing the duties of this job, the employee is regularly required to stand; walk; sit and talk or hear. The employee is occasionally required to use hands to finger, handle, or feel and reach with hands and arms.
• The employee may occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, depth perception and ability to adjust focus.

This description is intended to provide only basic guidelines for meeting job requirements. Duties and responsibilities, experience, qualifications, skills, supervisory relationship, physical/mental demands, and environmental/ working conditions may change as needs evolve.

Base salary offers for this position may vary based on factors such as location, skills and relevant experience. We offer the following benefits to those who are benefit eligible (30+ hours a week): medical, dental, vision, life and AD&D insurance, long and short term disability, 401k program with company match and profit sharing, wellness program, health savings accounts, flexible savings accounts, ID protection plan and accident, critical illness and hospital benefits. In addition, we offer paid holidays and paid time off.

Illinois Bone and Joint Institute, LLC is an equal opportunity employer. All employment decisions are based on qualifications, merit, and business need, without regard to race, color, religion, age, sex, national origin, disability status, military or veteran status, sexual orientation, gender identity and expression, or any other characteristic protected by federal, state or local laws. This policy applies to recruitment and placement, promotion, training, transfer, retention, rate of pay and all other terms and conditions of employment.

Salary Description

$125,000 - $150,000 Annually