Manager of Quality, Infection and Risk

Job Description

Job Description

Position Overview

Andrews ASC is seeking a dedicated and detail-oriented Manager of Quality, Infection, and Risk to lead and support our performance-improvement, risk management, and infection control programs. This role is essential to maintaining our high standards of patient care, regulatory compliance, and operational excellence. The ideal candidate will be a licensed RN with a strong background in healthcare quality, infection prevention, and regulatory affairs—especially within ambulatory surgical settings.

Key Responsibilities Regulatory Compliance

Stay current on federal / state laws, accreditation standards, and professional regulations

Submit required reports and applications (e.g., AAAHC, state surveys) in a timely manner

Develop and recommend policies and procedures to ensure compliance

Maintain access to state and federal quality reporting programs

Performance Improvement (CQI)

Assist in developing and implementing the facility’s performance-improvement program

Maintain and update PI policies, procedures, and documentation

Organize and participate in PAC / Quality Committee meetings and educational activities

Complete monthly / quarterly quality reports and two annual quality studies

Coordinate data collection, analysis, and reporting for patient care quality metrics

Evaluate grievances and recommend improvements to care standards

Maintain PI status logs and ensure facility drills are scheduled and completed

Complete annual Hazard and Vulnerability Assessment and update CEMP plan

Serve as a resource for staff education on PI and regulatory updates

Infection Control

Conduct monthly infection control rounding and surveillance activities

Identify and mitigate infection risks across all facility personnel and visitors

Coordinate infection control programs and staff education

Complete 30-day and 90-day infection reports and annual infection control assessment

Oversee TB evaluations and exposure tracking in collaboration with the Quality Coordinator

Monitor high-risk areas and analyze trends for improvement opportunities

Ensure compliance with infection control policies in partnership with the Director of Nursing

Asset Responsibility

Maintain confidential and organized records for all PI and infection control programs

Manage reference materials and documentation related to quality initiatives

Qualifications Required

Bachelor’s degree in Nursing

Active Florida RN License

BLS, ACLS, and PALS certifications

Experience in performance-improvement and risk management (certification preferred)

Strong ethical character and professional communication skills

Healthcare experience with a focus on quality and compliance

Preferred

Operating Room (OR) experience

Experience in Ambulatory Surgery Center (ASC) settings

Ideal Candidate Attributes

Cooperative and professional demeanor with staff, patients, and physicians

Strong decision-making and problem-solving abilities

Ability to promote a positive image of the facility to the public and stakeholders

BENEFITS :

• Health Insurance with FREE Teladoc services
• Dental, Vision, & Supplemental Insurance
• 401 (k)
• Paid Time Off

Location : Andrews Ambulatory Surgery Center – Gulf Breeze, FL

Department : Quality & Compliance

Reports To : Director of Nursing

Employment Type : Full-Time, Exempt

The Andrews Institute ASC (AIASC) is committed to promoting health, wellness, and disease prevention and to providing a safe, clean and healthy environment to Workforce Members, patients, and visitors. The use of tobacco and tobacco products is a known and established hazard to the health and well-being of tobacco users and can also directly impact nonusers. In addition, the use of tobacco and tobacco products has been shown to decrease employee productivity and efficiency and increase absenteeism. In recognition of these factors, the Andrews Institute ASC will no longer hire tobacco users.