Manager Surgical Services, Clinical Transformation & Quality

POSITION SUMMARY :

Reporting to the Senior Director of Surgical Services, the Surgical Services Manager is responsible for executing strategic initiatives and ensuring successful outcomes that optimize surgical and procedural care delivery in alignment with leadership decisions.
This role directly supervises the Surgical Scheduling team and serves as project manager for clinical transformation and quality initiatives designed to improve workflows, reduce inefficiencies, and enhance patient outcomes across surgical and procedural services.

Position: Manager Surgical Services, Clinical Transformation & Quality
Department: Pre-Procedure Processing

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Clinical Transformation & Quality

• Execute clinical transformation and performance improvement initiatives as directed by leadership, ensuring defined objectives and outcomes are achieved.

• Review, develop, and support revision of departmental policies and procedures in alignment with regulatory standards and organizational priorities.

• Review and synthesize evidence-based literature to inform clinical practice improvements and support implementation of standardized, best-practice protocols.

• Analyze workflows and quality data to identify improvement opportunities and develop implementation plans aligned with leadership direction.

• Support quality assurance activities by monitoring patient safety metrics, surgical/procedural outcomes, and infection control audits to ensure regulatory and accreditation compliance (Joint Commission, CMS, state regulations).

• Conduct root cause analyses for adverse events and support implementation of corrective actions.

• Educate staff on quality improvement and patient safety practices to promote adoption of standardized processes.

• Serve as designee for the Senior Director in hospital quality, risk/safety, and related leadership committees as needed.

Operational Management & Leadership

• Oversee daily operations of the Surgical Scheduling team.

• Analyze and filter key operational data; prepare reports and presentations on project progress, metrics, and outcomes for leadership.

• Coordinate cross-functional teams and committees to implement initiatives approved by leadership.

• Support the Senior Director in achieving strategic goals for the organization.

• Carry out other administrative and operational duties as delegated.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required)

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

• Master’s degree in, or active matriculation in a Master’s degree program, in Nursing, Healthcare Administration, Public Health, Business Administration, or related field required.

• Minimum of five (5) years' experience in surgical/perioperative services.

• Experience in a leadership, project management, healthcare quality or clinical operations.

• Demonstrated experience leading clinical transformation, performance improvement, or quality initiatives within a healthcare setting.

• Experience with regulatory and accreditation standards, including Joint Commission, CMS, and state regulatory requirements.

• Experience analyzing clinical and operational data to support performance improvement, reporting, and decision support.

PREFERRED EDUCATION AND EXPERIENCE:

• Experience in an academic medical center or complex healthcare environment.

• Experience supporting policy development, evidence-based practice implementation, and clinical protocol standardization.

• Familiarity with EPIC or other major electronic health record systems.

CERTIFICATIONS, LICENSES, REGISTRATIONS REQUIRED:

• Current Registered Nurse (RN) license in good standing.

CERTIFICATIONS, LICENSES, REGISTRATIONS PREFERRED:

• Advanced certification in perioperative nursing (CNOR), healthcare quality (CPHQ), or related specialty certifications such as Lean, PDSA, Six Sigma, IHI Quality Improvement.

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Analytical skills with the ability to identify risks and develop effective solutions, strong attention to detail.

• Experience working in matrixed environme