Job Summary:

The Director of Nursing and MBSAQIP Coordinator/Clinical Reviewer plays a vital leadership role in ensuring the delivery of safe, high-quality, patient-centered care and in achieving and maintaining accreditation from AAAHC, ACHA, and MBSAQIP. This role will oversee clinical operations, manage nursing staff, support EMR integration, and ensure ongoing compliance with all regulatory bodies.

Background Screening Information:
This position requires a background screening through the Florida Care Provider Background Screening Clearinghouse. For information about the screening standards and process, visit the official resource at https://info.flclearinghouse.com.

Key Responsibilities:

1. Clinical Leadership and Management

• Direct and oversee nursing staff in pre-op, intra-op, and post-op care.
• Coordinate efficient patient flow and ensure safe, quality care delivery.
• Provide direct clinical support and supervision as needed.

2. Accreditation & Compliance

• Lead initiatives to meet and maintain AAAHC, ACHA, and MBSAQIP standards.
• Prepare for and conduct mock surveys and staff training sessions.
• Oversee infection control, HIPAA, medication safety, and all compliance programs.
• Ensure documentation practices meet Health Information Management standards.

3. MBSAQIP Clinical Reviewer and Coordinator Duties

• Collect, track, and submit required MBSAQIP clinical data.
• Coordinate follow-up protocols for bariatric patients to ensure outcomes tracking.
• Lead Quality Improvement initiatives based on bariatric outcomes data.
• Train staff on MBSAQIP safety protocols and develop compliance systems.

4. System Implementation & EMR Superuser

• Develop expertise in SIS Complete EMR and act as a superuser.
• Train new nurses and staff on EMR utilization and documentation workflows.
• Monitor system performance and address gaps in real-time training.

5. Staff Recruitment, Training, Education & Retention

• Lead recruitment and onboarding of nursing and clinical staff.
• Ensure robust training programs and professional development opportunities.
• Maintain a high-retention culture and address team concerns proactively.

6. Patient Care & Satisfaction

• Ensure patient-centered practices and timely care from check-in to discharge.
• Respond to patient concerns and implement satisfaction initiatives.
• Maintain a satisfaction rating above 90% and lead continuous quality monitoring.

7. Performance Improvement & Committee Involvement

• Lead QI studies, track infection control data, and oversee performance improvement plans.
• Participate in Quality Subcommittees and Medical Advisory Committee (MAC) (see Exhibit A).
• Review and implement policies for EOC/Safety (e.g., Hazardous Waste, Fire Safety, Emergency Management).
• Ensure Health Information Management compliance (e.g., Medical Records, H&P documentation, Dictation/Transcription).
• Contribute to Performance Improvement initiatives (e.g., QI studies, incident report reviews, risk management).
• Support Pharmacy & Therapeutics efforts (e.g., medication safety, formulary management, antibiotic stewardship).
• Lead Infection Control and Prevention activities (e.g., IC logs, healthcare-acquired infection tracking, employee vaccines).

8. Team Development & Culture

• Foster a positive, inclusive, and high-performing clinical environment.
• Provide mentorship and encourage leadership at all levels.
• Support ongoing staff development through evaluations and annual reviews.

Expectations for Success:

• Maintain MBSAQIP accreditation
• Develop and maintain quality and safety protocols.
• Optimize team performance, patient outcomes, and operational efficiency.
• Support cost-conscious, high-quality care and contribute to institutional growth and expansion.
• Develop proficiency in the EMR SIS Complete system and serve as a superuser for nursing functionality, providing training and onboarding support to new nurses to ensure effective system utilization and seamless integration into clinical workflows.
• Participation in Performance Evaluations and Annual Reviews

Licensure, Certifications, and Pre-Hire Requirements

Your employment is contingent upon successful completion of all pre-employment requirements, including: 

• Active Registered Nurse (RN) license in the State of Florida 
• Current BLS and ACLS certifications 
• Satisfactory background check and reference verification 
• Basic computer proficiency
• Completion of all required onboarding documents 
• Ability to read and communicate effectively in English. Additional languages are preferred  
• Visual and hearing senses must be adequate to provide patient care  
• Proficient in problem-solving, decision-making, and conflict resolution
• Knowledge of performance improvement methodologies and risk management
• Ability to interpret and apply clinical guidelines, regulatory standards, and safety protocols
• Strong leadership, communication, and interpersonal skills
• Preferred: 1 year management or supervisory experience in ambulatory care
• Minimum of 2 years experience in a surgical, PACU, or ICU setting

You will also be required to review and comply with all institutional policies, including safety, infection control, patient confidentiality, and clinical protocols.