Registered Nurse Quality, Safety & Credentialing Manager

United Surgical Partners International

Johnson City, TN

JOB DETAILS
SKILLS
Accreditation Standards, Auditing, Clinical Medicine, Clinical Monitoring, Clinical Outcomes, Content Management Systems (CMS), Facilities Management, Healthcare, Healthcare Quality, Infection Control, Knowledge Base, Leadership, Maintain Compliance, Nursing, Orthopedics, Patient Care, Patient Safety, Performance Management, Performance Metrics, Prescription Drugs, Provider Credentialing, Quality Assurance, Quality Management, Registered Nurse (RN), Regulations, Regulatory Compliance, Regulatory Requirements, Retirement Planning, Risk Analysis, Risk Management, Safety/Work Safety, State Laws and Regulations, Surgical Procedures, The Joint Commission (TJC), Trend Analysis
LOCATION
Johnson City, TN
POSTED
11 days ago

Quality, Safety, & Credentialing Manager (RN)

At Mountain Empire Surgery Center, we believe health and care are inseparable. We are committed to delivering a high-quality, service-oriented environment for every patient undergoing a surgical procedure.

The center features four operating rooms and supports procedures in ENT, orthopedics, same-day joint replacement, same-day spine surgery, and the ROSA Knee System.

Position Summary

The Quality, Safety, & Credentialing Manager (RN) is responsible for leading the facility’s quality assurance, patient safety, regulatory compliance, and credentialing programs. This role ensures adherence to accreditation standards, promotes a culture of safety, and supports continuous performance improvement initiatives across the surgery center.

Key Responsibilities

Quality & Performance Improvement

  • Develop, implement, and manage the facility’s Quality Assurance and Performance Improvement (QAPI) program
  • Monitor clinical outcomes and performance metrics to identify trends and opportunities for improvement
  • Lead quality initiatives that enhance patient care, safety, and operational efficiency
  • Prepare and present quality reports to leadership and governing body

Patient Safety & Compliance

  • Promote a culture of patient safety and regulatory compliance
  • Ensure compliance with The Joint Commission, CMS, and state regulations
  • Conduct audits, risk assessments, and incident investigations
  • Oversee infection prevention and control programs

Credentialing & Privileging

  • Manage provider credentialing and recredentialing processes
  • Maintain accurate and up-to-date provider files in accordance with regulatory requirements
  • Coordinate privileging activities and ensure compliance with medical staff bylaws
  • Serve as liaison between providers, administration, and credentialing bodies

Qualifications

Required:

  • Current Registered Nurse (RN) license
  • Bachelor’s degree in Nursing (BSN)
  • Minimum of 3–5 years of clinical experience in a surgical or perioperative setting
  • Experience in quality, risk management, or regulatory compliance
  • Strong knowledge of The Joint Commission standards and healthcare regulations

Preferred:

  • Certification in Healthcare Quality (CPHQ) or related field
  • Prior experience in an ambulatory surgery center (ASC)
  • Experience with credentialing and privileging processes

What We Offer

As an organization, one way we care for our communities and each other is by providing a comprehensive benefits package that includes the following, subject to employment status:

·Medical, dental, vision, and prescription coverage

·Life and AD&D coverage

·Availability of short- and long-term disability

·Flexible financial benefits including FSAs and HSAs

·401(k) and access to retirement planning

·Paid holidays and vacation

Who We Are

At USPI, we create relationships that create better care. We partner with physicians and healthcare systems to provide first-class ambulatory solutions throughout the United States. We are committed to providing surgical services in the most efficient and clinically excellent manner.

USPI is committed to, and proud of our inclusive culture. An inclusive culture, in our view, is respectful of differences and nurtures and supports the contributions of each individual, while also embracing and leveraging diversity. A diverse workforce, combined with an inclusive culture, makes USPI stronger and better able to meet the needs of our diverse patient and physician population.

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About the Company

U

United Surgical Partners International

Strength in Numbers
United Surgical Partners International (USPI) and Tenet have combined forces to create the nation’s largest ambulatory surgery provider. Our combined network of exceptional surgical and imaging facilities includes approximately 20 imaging centers, and over 265 short-stay surgical facilities. Together, our partnerships include 50 health systems and more than 4,000 physicians.

Nationwide Experience
Our partners deliver high quality ambulatory solutions in safe, efficient and caring USPI facilities in communities of every size across 29 states. Our physician partners are focused on providing quality patient care, in part because they are invested in their USPI facility. We provide the infrastructure and support they need to perform their best. This is one of the advantages of partnering with USPI.

Quality Patient Services
We share a vision with our physician and health system partners. Our goal is to provide the quality of healthcare services we would insist upon for our own families. Since our founding in 1998, this goal has helped us grow exponentially. Today, our strategic joint venture with Tenet establishes USPI as one of the nation's leading providers of ambulatory solutions.

Operating Excellence
Our size and experience in developing and operating ambulatory facilities and strategic vision allow our facilities to achieve both high patient satisfaction and solid financial results. Moreover, because we engage physicians in the governance and growth of the facility, we also achieve excellent clinical outcomes.

COMPANY SIZE
10,000 employees or more
INDUSTRY
Healthcare Services
FOUNDED
1998
WEBSITE
http://www.uspi.com/