Job Description

The ASC Accreditation & Compliance Specialist is Acuity Eye Group's centralized subject matter expert for ambulatory surgery center accreditation and regulatory compliance. Operating in a shared SME model across all ASC locations, this role is accountable for continuous survey readiness, internal audits, corrective action management, clinical compliance monitoring, and QAPI support — ensuring every Acuity ASC remains fully accredited and survey-ready at all times.

This role partners closely with the COO, Medical Director, Regional Directors, Site Administrators, and Charge Nurses. The Specialist is the compliance anchor for the ASC portfolio — not embedded at a single site, but a consistent, trusted resource across all of them.

Key Responsibilities:

• Conduct scheduled and unannounced internal audits at all ASC locations per the annual audit calendar, covering full compliance audits, focused clinical audits, documentation spot checks, and pre-survey readiness audits
• Assess compliance with AAAHC, Quad A, and CMS Conditions for Coverage standards and applicable California state regulations
• Classify findings using the five-tier framework (Compliant / Observation / Minor / Major / Immediate Threat); deliver written audit reports within 48 hours of each site visit
• Track all corrective action plans (CAPs) from initiation through verified closure; maintain evidence documentation and confirm implementation with site staff
• Escalate Immediate Threat findings to COO and Medical Director same day; Major findings within 24 hours per the escalation matrix
• Lead site preparation beginning at T-90 days prior to survey: gap analysis, mock surveys, documentation review, staff readiness briefings, and evidence binder completeness audits
• Conduct full mock surveys using accreditation body surveyor methodology; issue written mock survey reports within 72 hours
• Maintain organized, current evidence binders at each site across all required domains: governance, credentialing, policies, QAPI, infection control, medication management, patient records, emergency preparedness, environment of care, and personnel
• Monitor AAAHC, Quad A, and CMS standards for updates; prepare change summary memos and coordinate policy revisions within 30 days of any standards change
• Maintain the master policy library for all ASC sites; ensure all policies reflect current standards and are reviewed within the prior 12 months
• Review clinical documentation, infection control logs, sterilization records, biological indicator results, medication management logs, and quality indicators on a structured monitoring schedule
• Conduct monthly sterilization log reviews; quarterly infection control observations; 10% patient record sample audits per cycle (H&P currency, informed consent, discharge documentation)
• Support investigation of patient safety events and complaints: gather records, complete Root Cause Analysis for threshold events, prepare summary reports for Medical Director within 5 business days
• Monitor provider credentialing currency monthly; flag license, DEA, ACLS/BLS, and privileging expirations in advance to Credentialing and HR
• Serve as a standing QAPI participant at all ASC locations; prepare audit summaries, CAP status reports, and compliance trend analyses for each meeting
• Collect and report on key quality indicators: surgical site infection rates, unplanned hospital transfers, consent completeness, sterilization pass rates, and staff drill compliance
• Deliver the Monthly Compliance Dashboard to COO by the 5th of each month; present Quarterly Compliance Summary at leadership QAPI meeting

Requirements

Education and Communication:

• Communicate audit findings to site staff constructively; conduct closing conferences at each audit visit and distribute written reports to site admin and Regional Director
• Develop and distribute compliance education materials, policy updates, and standards change communications across all sites
• Facilitate weekly 15-minute compliance standups with each site administrator covering open CAPs, upcoming deadlines, safety events, and policy updates
• Serve as the day-to-day resource for site administrators, charge nurses, and clinical staff on all accreditation and compliance questions

Required Qualifications:

• 2+ years in ASC, hospital, or outpatient clinical compliance, quality, or accreditation support
• Working knowledge of AAAHC, Quad A, or CMS ASC Conditions for Coverage
• Experience conducting internal audits and managing CAPs to verified closure
• Ability to manage concurrent priorities across multiple sites
• Clear written and verbal communication; comfortable with clinical staff and leadership
• Proficiency in Microsoft Office; experience with audit tracking tools a plus
• Ability to travel regularly across Southern California ASC locations

Preferred Qualifications:

• Clinical background: RN, Surgical Tech, or allied health credential
• Multi-site ASC experience with direct accreditation survey preparation responsibility
• Ophthalmology ASC experience strongly preferred
• Experience with QAPI program development and quality indicator reporting
• Familiarity with infection control and sterilization compliance in a surgical setting
• Prior experience as primary contact with an accreditation surveyor during a live survey