Illinois Bone & Joint Institute

Clinical Operations

• Oversee quality and accreditations for ambulatory surgery centers
• Ensure ambulatory surgery centers meet required quality and safety standards
• Collaborate with site Administrators to implement Joint Commission, AAAHC, and regulatory standards
• Develop quality dashboards for internal and external customers
• Serve on Medical Executive Committees and quality committees for all IBJI ambulatory surgery centers
• Ensure adherence to state, federal, CMS, JCAHO, AAAHC, and other accreditation standards
• Lead preparation for accreditation surveys
• Communicate with accreditation bodies and maintain required policies, procedures, and documentation
• Participate in ASC Medical Executive, Quality, and other relevant committees
• Partner with the Corporate Manager of Payer Relations to provide timely quality data to third-party administrators
• Develop, implement, evaluate, and enforce facility policies, procedures, goals, and objectives
• Develop and oversee quality improvement, quality management, utilization review, discharge planning, infection control, and risk management programs
• Direct preparation and maintenance of patients' clinical records
• Collect, analyze, and interpret data from patient records, feedback, and risk assessments
• Prepare reports on quality improvement activities and organizational performance
• Consult with nurse managers and medical staff on patient care and nursing problems
• Visit departments to observe procedures and recommend improvements
• Participate in facility program development and modification
• Educate and train staff on accreditation standards, quality improvement, risk management, and care protocols
• Identify process improvements and implement initiatives to enhance patient safety and quality of care
• Collaborate with nursing, physician, and administrative teams to establish facility-wide goals
• Review clinical care practices, analyze patient feedback and facility records, and promote healthcare initiatives
• Partner with Administrators to help direct care in nursing and clinical areas
• Carry out supervisory responsibilities according to organizational policies and applicable laws
• Perform other duties as assigned

Clinical Manager – Quality & Accreditations

Credentialing Specialist

• Secure and maintain critical provider credentials for the Ambulatory Surgery Center
• Manage the end-to-end credentialing and re-credentialing lifecycle for medical staff
• Serve as internal expert on state licensing and facility privileges
• Lead enrollment for government and commercial payors
• Ensure quality, accuracy and timeliness of primary source verification
• Prepare, populate and submit initial credentialing and re-credentialing applications
• Plan, manage and execute cyclical reappointment for active medical staff
• Partner with hospitals and providers to streamline document collection and credentialing workflow
• Update credentialing files, tracking tools and internal task lists
• Complete designated credentialing tasks within the onboarding checklist
• Perform monthly audits of expiring licenses, DEA documentation and board certifications
• Document workflow steps, provider numbers, effective dates and official correspondence
• Conduct outreach regarding pending credentials or documentation bottlenecks
• Liaise with physicians, external clients and internal teams regarding credentialing updates
• Help maintain and distribute active provider and physician schedules
• Perform clerical functions including high-volume data entry, faxing, scanning and digital filing
• Assist other areas as needed
• Maintain a safe, clean and organized workspace