About the role
Description Position Summary:
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