Reports to: Vice President, Ambulatory Surgery

Supervisory Responsibilities: Managers and staff.

Status – Exempt position

Essential Responsibility: Fulfills the organization’s goals, mission and objectives

Ensures the provision of high-quality safe care.

Ensures the business operates in an efficient, safe, complaint and ethical manner.

Education: Bachelor’s degree - Business Administration preferred.

Experience: Minimum of three years in multispecialty ASC environment.

Operational Responsibilities include but are not limited to:

Patient Rights

Ensures that all required postings including Patient Rights and Responsibilities, Grievance procedure and information on Advance Directives are clearly visible. Documents the review and any necessary modifications/updates of the Patient Rights program annually and documents such activity in the in the Governing Body meeting Minutes. Performs random medical chart audits to confirm patients have acknowledged receipt of the above. Establish a patient satisfaction program including analysis of data and reports results with analysis and recommendations to the Governing Body Confirms patient privacy practices are being followed and documented during monthly environmental rounds.

Administration

Enforces policies and procedures delegated by the Governing Body. Takes reasonable steps to comply with all applicable Federal and State laws and regulations. Maintains the center in ready state for regulatory inspection and accreditation. Employs qualified personnel by following all Human Resource policies and procedures. Maintains and updates all personnel and credentialing files by developing and managing a surveillance system for expired documents. Ensures all annual staff performance and compensation evaluations. Develop and maintain all contracts and ensures review and documentation of the effectiveness of the contracted services and reports the analyzed results with recommendations to the Governing Body. Maintains all personnel and physician medical files and tracks date sensitive documents Ensures completion of all annual mandatory education and competencies of staff. Keeps current with the Standards of Care. Protects all assets of the organization utilizing industry standard best practices Risk Management policies and procedures. Monitors and ensures a functioning facility by monitoring the repair and maintenance of all facility systems and infrastructure, equipment, cleanliness.

Quality Improvement

Maintains an active, integrated, data driven, peer-based Quality Improvement program. Conducts ongoing audits and quality improvement internal and external benchmarking studies resulting in the improvement of care. Reports all quality improvement activities, results, and corrective actions to the Governing Body. Develops quality indicators, sets quality improvement performance goals and supervises and analyzes the collection of data.

Medical Records

Maintains a secure electronic clinical records system Periodically audits the records for completion of all required information and manages results according to Governing Board objectives. Ensures the security and privacy of all Protected Health Information by following all HIPAA Privacy and Security Rules by ongoing surveillance and audits and reports findings with recommendations to the Governing Body. Develop a mechanism to summarize treatment of anyone with three or more visits to ensure the continuity of care. Develop a mechanism by which all testing results and consults are acknowledged by the physician(s).

Infection Control, Patient Safety, and Risk Management

Ensures that all required mandatory in-services are completed within the last 12 months. Ensures and documents that all planned fire and disaster drills are completed, analyzed and corrective actions have been implemented quickly. Ensure that one designated clinical staff member and one backup has formal education in infection control. All reportable diseases are documented according to policy and reported to the proper authorities. All adverse incidents are documented according to policy and reported to the Governing Body. The medical records will be reviewed by the medical Director for quality and peer review issues. All clinical staff are monitored for safe injection practices and ensures proper documentation. The cleaning services are monitored to ensure all policies are met/exceeded regarding cleaning routines and the use of approved cleaning agents Instrument cleaning and sterilization practices and staff are monitored for compliance of the CDC, APIC, AAMI, AORN Infection Control Regulations and appropriately documented. All OSHA requirements will be continually monitored for compliance and appropriately documented.

Financial

Monitor and approve all expenditures within the set parameters. Monitor and approve all payroll activities to stay within the predefined staff budget. Performs financial analysis for new products and services. Performs and provides monthly budget variance analysis / explanation. Collaborates with service line leaders on new programs and growth initiatives.

Other Functions

1. Attends meetings and participates on committees.

2. Keeps current on the state of the ambulatory healthcare market.

3. Contributes to strategic planning initiatives.

Skills

Self-starter and independent thinker. Excellent communication skills Strong organizational skills Strong computer skills Understands and practices strong group practice skills to create a positive forward-thinking environment Strong work ethic

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Weekend availability

Ability to commute/relocate:

• Berkeley Heights, NJ 07922: Reliably commute or planning to relocate before starting work (Required)

Application Question(s):

• Do you have a preferred Business Administration degree?

Education:

• Bachelor's (Required)

Experience:

• multi-specialty ASC environment: 3 years (Required)

Work Location: In person

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