Clinical Quality & Education Specialist

The Clinical Quality & Education Specialist is responsible for coordinating the Quality Assessment and Performance Improvement (QAPI), Infection Prevention, Risk Management, Regulatory Compliance, and Clinical Quality Education programs across assigned Ambulatory Surgery Centers. This position partners closely with Regional Clinical Directors and other key stakeholders to monitor quality performance, conduct audits, support accreditation readiness, investigate patient safety events, coordinate performance improvement initiatives, and provide targeted education based on regulatory requirements and identified performance gaps.

Essential Duties and Responsibilities:

• Quality Assurance

• Coordinate the ASC Quality Assessment and Performance Improvement (QAPI) Program.

• Monitor, analyze, and trend quality indicators and performance metrics.

• Conduct routine medical record, clinical, and documentation audits.

• Conduct routine quality and compliance rounds at assigned ASCs.

• Develop audit tools, dashboards, and tracking reports to support ASC operations.

• Prepare quality reports for the Quality Committee and Governing Board.

• Monitor completion of corrective action plans and performance improvement projects.

• Investigate quality concerns and assist Regional Clinical Directors with corrective action plans.

• Assist management and other key stakeholders in identifying opportunities for clinical and operational improvement.

• Provide guidance regarding CMS Conditions for Coverage, accreditation standards, infection prevention, and patient safety requirements.

• Coordinate regulatory readiness activities and assist centers with accreditation and licensing surveys.

• Identify education opportunities through routine audits and quality rounds.

• Partner with management and other key stakeholders to implement targeted improvement plans and staff education.

• Assist with competency remediation and follow-up when deficiencies are identified through audits, surveys, or event investigations.

• Infection Prevention

• Conduct annual Infection Prevention Risk Assessments.

• Perform infection surveillance, including surgical site infection (SSI) tracking.

• Conduct infection prevention rounds and compliance audits.

• Monitor sterilization and high-level disinfection processes.

• Coordinate required NHSN and regulatory reporting, as applicable.

• Provide infection prevention education and annual competency support.

• Monitor compliance with CDC, APIC, AORN, CMS, and Joint Commission infection prevention standards.

• Risk Management

• Investigate patient safety events, adverse events, and incident reports.

• Coordinate Root Cause Analyses (RCAs) and corrective action plans.

• Track and trend patient safety events to identify recurring opportunities for improvement.

• Assist with patient complaint investigations, as appropriate.

• Monitor completion and effectiveness of corrective actions following incident investigations.

• Prepare risk management reports and trending for leadership and Quality Committee review.

• Clinical Education & Competency Support

• Coordinate and support education related to quality improvement, patient safety, infection prevention, and regulatory compliance.

• Develop educational resources and competency tools based on audit findings, regulatory updates, accreditation standards, and identified performance gaps.

• Collaborate with management and other key stakeholders to provide focused education following quality audits, incident investigations, and survey findings.

• Assist with annual competency validation related to infection prevention, sterilization, moderate sedation, patient safety, and other regulatory requirements.

• Support orientation and onboarding of Lead RNs, ASC leadership, and clinical staff related to quality initiatives, QAPI, regulatory compliance, and accreditation standards.

• Serve as a resource to physicians and clinical staff regarding quality improvement initiatives, regulatory compliance, evidence-based practice, and patient safety.

• Checks and responds to work e-mail on a regular basis throughout the workday.

• Participates in and completes all required trainings and in-services.

• Performs other duties as assigned.

Minimum Qualifications:

• Bachelors Degree from an accredited college or university WITH a minimum of five (5) years of experience as a Registered Nurse, including at least two (2) years of experience in an Ambulatory Surgery Center; OR an equivalent combination of education and/or experience.
• Experience coordinating quality improvement, infection prevention, regulatory compliance, accreditation, or risk management activities is required.
• Must have knowledge of Internet and Microsoft Office software (MS Word, MS Excel, MS PowerPoint, MS Outlook).
• Must possess and maintain current licensure as a Registered Nurse in the state in which work is performed. Must possess a current ACLS and BLS certification.
• Must have at least two (2) years experience working with Joint Commission OR Center for Medicare and Medicaid Services (CMS) standards and regulations.
• Must have excellent written and oral communication skills, including exceptional customer service.
• Must be able to establish and maintain effective working relationships with doctors, clinical staff, other co-workers and the public.
• Must be able to work individually as well as within a team.
• Must be able to follow both verbal and written instructions.
• Must be able to work a flexible schedule.
• Must be able to respond with patience and understanding during stressful conditions related to patient health and emergent situations.
• Must be able to multi-task and prioritize.
• Must demonstrate extreme attention to detail.
• Must possess strong organization skills.
• Must be able to problem solve and use reasoning.
• Must be able to meet predefined quality standards.
• Must maintain and project a professional attitude and appearance at all time.
• Must have a working knowledge of the healthcare field and medical specialty, as well as medical terminology.
• All staff are expected to have a strong desire to provide excellent customer service; to comply with the rules and regulations of those organizations to which we are accountable; to have high ethical and professional standards of conduct; and to have an attitude of wanting to continuously improve their own professional performance.

Preferred Qualifications:

• Two (2) years experience managing an infection control and safety program.
• One (1) year of prior experience working with an Electronic Medical Record (EMR).

Driving/Travel:

The employee must have reliable transportation. Travel for this position may be required up to 100%. While the primary workplace may be closest to the employees home, work assignments could be in any of the Companys locations.

Compensation and Benefits:

• Pay Range: $105,600/year to $115,000 annually
• PTO: Up to 96 hours in first year (pro-rated based on start date)
• Holidays: 7 (New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, Day After Thanksgiving, Christmas Day)
• Retirement: 401(k) with employer match
• Health Benefits: Medical (single and family), Dental (single and family), Vision (single and family)
• Other Company-Paid Benefits: Short-Term Disability, Long-Term Disability, Basic Life/AD&D, Employee Assistance Program
• Other Voluntary Benefits: Voluntary Life, Accident, Critical Illness, Hospital Indemnity
• Other Compensation: This position is exempt (salaried) and is not eligible for overtime pay. This position is not eligible for bonus, commission, incentive, or shift differential pay.