Job Description

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.

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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