Director Quality Compliance – Regulatory - West Region (Remote)

Director Quality Compliance – Regulatory

AMSURG

Remote (Must Reside in the West Coast Region)

Company Overview: AMSURG is an independent leader in ambulatory surgery center services, operating a network of more than 250 surgery centers nationwide. In partnership with physicians and health systems, the organization delivers high-quality care for patients across a diverse spectrum of medical specialties, including gastroenterology, ophthalmology and orthopedics. To learn more about AMSURG, visit www.amsurg.com.

POSITION SUMMARY:

Provides direction and overall implementation of Regulatory and Accreditation plan of correction to maintain survey readiness. Promotes the advancement of patient safety, enhanced patient experience, quality performance, and regulatory/accreditation compliance at all centers and when assigned to conduct readiness assessment visits. Drives consistency in processes and creates opportunities for improvement.

Work Schedule: Remote First.

ESSENTIAL RESPONSIBILITIES:

• Requires an in-depth understanding of regulatory and accreditation regulations and standards by maintaining current knowledge which includes Medicare Conditions of Participation, The Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC), as well as State and Federal agencies. 
• Facilitate Plans of Correction (POC) to ensure their quality and timely completion,
• Assist in development and review of policies and procedures that ensure alignment with accreditation standards, state licensing requirements, and Medicare Conditions of Participation.
• Collaborate with Center Administrator and Corporate leadership on improvement efforts, including corrective actions post-survey.
• Provide education regarding standards and processes, including updates/revisions.
• Ensure timely documentation of survey activity, track and trend survey findings for benchmarking externally when possible.
• Assist with Clinical Risk Management investigations and reporting of events as required by external agencies when needed.
• Maintain collaborative relationships with Sr. Director Quality Compliance and appropriate agencies, AMSURG departments, and Centers.
• Assist in soliciting sustainable processes and system improvements that maintain quality metrics and/or regulation/accreditation-related objectives.
• Maintain and monitor all regulatory and deemed-status data related to survey activities and findings, ensure their timely compilation.
• Conduct survey performance readiness assessments when needed in preparation for regulatory and accreditation visits along with any specialty certifications, including:
• Observe facility staff roles to ensure we are providing the highest quality and safety of healthcare, with adherence to professional standards, licensures, and competencies.
• Review facility documents for continual content compliance.
• Tour interior and exterior physical environments for required equipment, supplies, continuous maintenance, and infection control.
• Follow a “tracer patient” throughout the patient experience from admission to discharge.
• Observes “high risk” processes, i.e., high level disinfection, instrument sterilization, etc.
• Adhere to all company policies and procedures, including Information Security Policies and ensure that AMSURG remains as secure as possible.
• Travel of up to 50% may be required by land and/or air.
• Regular and reliable attendance is required.

KNOWLEDGE AND SKILLS:

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily.  The requirements listed below are representative of the knowledge, skills and/or abilities required:

• Detail oriented and organized.
• High integrity, including maintenance of confidential information.
• Able to exercise good judgment and positively influence and lead others, including handling confrontations with poise and efficiency.

Education / Experience:

• An in-depth understanding of regulatory and accreditation regulations and standards is required by maintaining current knowledge, which includes Medicare Conditions of Participation, The Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC), as well as State and Federal agencies.
• Five+ years’ experience in Nursing/Healthcare.  
• Bachelor’s Degree from an Accredited College or University in Nursing or related Healthcare field.
• 2+ years’ Clinical experience in an Ambulatory Care setting.
• 3+ years in a leadership position preferred.
• Strong verbal and written