Manager, Quality, Risk & Compliance - Ambulatory Surgery Centers - Orlando Health

Manages Ambulatory Surgery Centers (ASC) based facility operations and ensures compliance with all statutes and guidelines that regulate ASC operations. Such regulatory entities include Agency for Healthcare Administration (AHCA), Regulatory Agency, State Department of Health, and the federal government. Helps manage all regulatory changes by keeping policies and procedures current. Ensures the ASC programs and services are implemented at the highest standard, so patients receive the highest level of care. Develops and coordinates facility or assigned area-wide systems for risk identification, investigation, and reduction; maintains a network of informational sources and experts; performs risk surveys and assesses patient care areas.

• In Collaboration with the Director, manages Facility Licensing, Accreditation and Operational Requirements for all surgery centers.
• Creates and maintains a process checklist to ensure ASC policies are up to date and maintained at the highest level.
• Monitors for regulatory changes as they occur and suggests changes when needed.
• Performs project audits to ensure quality assurance in all areas of the ASC, including financial, medical records, peer reviews, personnel, and credentialing audits.
• Facilitates all root causes analysis investigations and reporting of adverse events and sentinel events to the apparent parties.
• Provides proactive analysis of patient safety and medical errors processes.
• Liaison between all ASC management to aide in communication and consistency while considering the occasional need for a tailored approach due to some differences in facilities.
• Creates quarterly statistical reports for the Quality/Risk Management Committee and Board of Directors, leads Quality Management (QM) presentations, and submits minutes for QM and Board of Director (BOD) meetings.
• Reviews and prepares listing of current licenses inventory.
• Prepares tracking list of licenses required to be completed for an acquisition or new development, based on facility type and State and Federal requirements.
• Creates and submits licensure applications as required by state and federal requirements.
• Uses PECOS system for appropriate enrollment transactions.
• Renews facility licensure bi-annually with AHCA.
• Ensures all center licenses and business tax receipts are current (DEA, Pharmacy, Consultant Pharmacist, Radiation Machines, and Biomedical Waster Permits).
• Submits regulatory agency re-accreditation application and implementation of accreditation guidelines.
• Assists facilities in regulatory agency survey preparations.
• Maintains a continuous process for review/revision of ASC policies and procedures to align with regulatory compliance and/or facility protocols; updates policies as necessary and obtains all approval signatures.
• Coordinates Benchmarking and Quality Improvement Studies, suggests projects/quality measures that necessitate more in-depth analysis and oversees clinical QI study data collection activities. Documents all activities in AAAHC approved format and report such activities to QM and BOD.
• Assists Risk Manager at each Center with resolution/medical records procurement for adverse incident reports and Ad Hoc Peer Review.
• Assists with monitoring for peer review completion/process.
• Assists with monitoring for compliance and completion of monthly infection control survey process.
• Maintains Job Descriptions for all ASC department positions and edits as proposed and approved by appropriate personnel.
• Assists with data collection and submission of CMS mandated Quality Measures through Quality Net/HARP portal.
• Ensures compliance with regulatory requirements regarding mandatory drills, risk assessments, and staff annual in- services.
• Attends Regulatory meetings and provides Quality and Compliance related input.
• Creates/updates online training modules through the Learning Management System.
• Reports Florida Cancer Data annually.
• Assists with the credentialing process when needed to ensure compliance.
• Assists with the submission of the Comprehension Emergency Management Plan as needed.
• Ensures knowledge of any regulatory changes needed before submission.
• Ensures all centers are maintained and are up to date on staff and provider information in appropriate folders such as license, training, etc.
• Monitors all required forms are submitted to HR and ensures they are completed consistently and in compliance with OH policy.
• Facilitates office communication.
• Notifies and helps educate clinical supervisors and staff of new policies and procedures or changes.
• Identifies and communicates potential conflicts to center’s strategic plans and goals, provides additional insight and suggestions when appropriate.
• Helps communicate to other offices within OH all items that would affect their processes or items that require the ASC’s cooperation. This internal communication will always be one that strives to send message of teamwork and cooperation support the ASC’s needs as well.
• Attends OH leadership/training classes when appropriate.
• Assists Regional Director and Administrator in financial performance of each facility.
• Assist in collecting data as assigned and various tracking reports.
• Assist in financial and chart audits.

Other Related Functions

• Performs other incidental and related duties as required and assigned.
• Attends at least one ASC meeting annually. Florida Society Ambulatory Surgery Center (FSASC), Risk Management or AAAHC.

Education/Training

• Bachelor’s Degree in Nursing required.

Experience

• 3 Years OR/ASC experience.
• Extensive knowledge of healthcare compliance, regulatory requirements, and CMS regulations.
• Knowledge of AHCA licensure requirements and accreditation standards.
• Strong Leadership skills.
• Excellent interpersonal and communication skills.
• Strong customer service orientation.
• Strong computer skills.