Assistant Clinical Director

Join Our Mission to Elevate Ambulatory Health Care

At AAAHC, we are more than just a team; we are at the forefront of improving health care quality through accreditation. Our employees are the heartbeat of our mission-based culture, dedicated to applying their diverse skill sets—technical, research, clinical, analytical, and data-driven—to improve health care quality through accreditation. As we celebrate over four decades of excellence, we invite you to become part of our story. Here, your work is not just a job; it’s a journey filled with opportunities to learn, grow, and contribute to a higher purpose. Embrace the chance to be part of a community that values quality every day and strives for excellence in ambulatory health care.

What do we offer?

We prioritize our employees’ wellbeing by providing a comprehensive benefits package that includes:

• Compensation: Receive annual merit increase consideration and an annual discretionary bonus
• Work-Life Balance: Enjoy generous paid holidays, increasing paid time off with tenure, and potential hybrid schedule eligibility
• Health & Wellness: Take advantage of our medical, dental, and vision plans including company contributions to HSA as well as our wellness reimbursement benefit
• Retirement Plan: Invest in your future with our robust 401(k) plan that includes a company contribution and match
• Professional Development: Advance your career with ongoing training and educational opportunities along with a tuition reimbursement program
• Life & Disability Insurance: Experience peace of mind with company-paid short/long-term disability, life, & AD&D insurance
• Employee Assistance Program: Access support services for personal needs

Position Description 

Reporting to the SVP, Chief Clinical Officer, the Assistant Clinical Director has primary responsibility for addressing Standards interpretation questions and serves as backup support to clinical complaint investigations, escalated Survey Report and Plans of Correction (POC) review, and Immediate Jeopardy situation management for all AAAHC accreditation and certification programs. This position establishes structured procedures to ensure timely response to stakeholder (i.e., staff, clients and surveyors) Standards and AAAHC process questions and monitors frequently asked questions to inform improvements to Standards, education, policies and procedures, and other communication. It requires leveraging clinical knowledge and a deep understanding of AAAHC Standards to directly address questions and triage to subject matter experts (SMEs) across the organization and among AAAHC volunteer Expert Content Committees as appropriate.

Success in this role requires a clinical background, knowledge and utilization of accreditation standards in a clinical setting, effective project management and multitasking, with focus on timeliness, thoroughness, accuracy, consistency, and organization

Manage AAAHC Standards interpretation stakeholder support ensuring timely, consistent, and accurate responses directly tied to AAAHC Standards, policies and procedures, and practices

• Establish a comprehensive database for documentation and analysis of stakeholder questions and AAAHC responses, and easy extract for FAQ assembly; database elements should at minimum include: question receipt and response date, question source date; stakeholder questions come from client and surveyor education programs, AAAHC question inboxes (e.g., info@aaahc.org), other staff and escalated survey report and POC review, connection to AAAHC Standards and policies as appropriate; segmented by Standards Category, references, source question and aggregated question, AAAHC response in consistent format, SME utilization/name
• Aggregate similar questions for response consolidation; establish, implement, and educate other SMEs on a consistent syntax for question revisions and responses ensuring segmentation as appropriate for surgical vs. primary care, specialty, facility type, population type, or other factors that warrant specific responses
• Establish procedures for and routinely maintain database including updating Standards assignment with version publications, updating references, retiring questions that are no longer relevant, and refining responses as necessary with changes in Standards interpretation, AAAHC policy, and operational procedures
• Establish mechanisms to monitor question frequency for determination of Frequently Asked Questions (FAQs) to inform improvements to Standards, education, policies and procedures, tools/other resources, and other communication; routinely (at least quarterly) contribute to Standards Development category review with insight extracted from database analysis
• Leveraging clinical and Standards interpretation knowledge, directly address stakeholder questions, or triage to internal subject matter experts (SMEs) and among AAAHC volunteer Expert Content Committees as appropriate; includes both clinical and physical environment/life safety questions
• Monitor response turnaround (TAT) by SME; implement process improvements/corrective action as necessary to achieve TAT targets
• Develop specifications for automation of FAQ processes and investigate system solutions with consideration for other AAAHC customer service business needs

Provide support to clinical complaint investigations, escalated Survey Report and Plans of Correction (POC) review, and Immediate Jeopardy situation management for all AAAHC accreditation and certification programs; time allocation for related activities estimated not to exceed 40%

• Support complaint investigation process leveraging Standards knowledge, clinical expertise, and effective project management for timely and thorough documentation, categorization, and assessment of complaint issues raised against an existing or previous organization awarded AAAHC accreditation or certification. Complaints include information received suggesting or claiming a quality breach (e.g., adverse events pertaining to a patient or facility employee, infection control breaches) related to AAAHC Standards that can be sourced from a variety of entities (e.g., current/former facility employee(s), patients, other public sources, CMS or state agencies, or the media)
• Serve as the AAAHC Standards clinical SME for internal and external stakeholders
  • Provide timely response to client, staff, and surveyor requests for Standards interpretation
  • Contribute to Standards development through analysis of frequently asked questions
  • Contribute to content for stakeholder tools and resources, education, Triangle Times Today, and other communications
  • Serve as faculty for client, staff, and surveyor education/training
• Serve as the AAAHC Standards clinical SME for internal and external stakeholders
  • Review complex survey reports to determine appropriate deficiency level for the environment
  • Collaborate with Clinical Triage Team to identify and manage immediate jeopardy, infection control breaches, and other patient safety concerns
  • Review Change Notifications to determine need for information, onsite survey, or escalation to the Accreditation Committee (AC)
  • Review escalated objections documented in POCs; research requirements, discuss with surveyors, and conduct client conference calls to de-escalate and educate

Committee and Technical Panel Support

• Serve as secondary Staff Liaison to AAAHC Complaints Investigation Committee (CIC) supporting primary liaison with meeting/conference call schedule, agenda and related materials development, meeting minutes draft/approval, official memos drafts/revisions resulting from CIC decisions, decision documentation, and timely complaint triage, action, and findings communication; maintain BoardEffect portal information for committee communication and minutes approval
• Achieve and maintain 1095 Engage AAAHC Accreditation Management System proficiency in general, and specifically the Investigation module; participate in UAT as necessary for system enhancements
• Maintain up-to-date knowledge of infection control, AAAHC Standards and programs, and CMS and state regulatory requirements; communicate technical changes across AAAHC as appropriate
• Maintain proficiency as a AAAHC Surveyor including Team Lead and MDS badging, completing at least three Surveys each year

Minimum Qualifications and Job-specific Competencies Required

• Minimum of 5 years ambulatory or hospital experience in a clinical, quality improvement, education role or regulatory role (e.g., clinical nurse leader, nurse manager, quality improvement specialist, nurse educator, or occupational safety and health specialist)
• Current clinical certification/licensure [e.g., Registered Nurse (RN), Advanced Practice Nurse (APRN), Physician’s Assistant (PA)] 
• Active involvement with organization compliance to health care accreditation standards and third-party onsite survey participation
• Demonstrated project management experience and ability to multitask requiring minimal supervision and direction; experience indirectly managing cross-functional project teams and building consensus
• Strong analytical skills; independent thinker with proven technical acumen in problem-solving and analyzing datasets; intense attention to detail
• Advanced reasoning, critical thinking, and language abilities with effective communication, technical writing and editing, and presentation skills to a variety of audiences
• Discrete; ability to manage confidential information appropriately
• Proficiency with MS Office products (e.g., Word, Excel, PowerPoint

Preferred Qualifications

• People management experience
• Experience maintaining compliance to CMS Conditions for Coverage
• Certified Professional in Health Care Quality (CPHQ) or other demonstrated knowledge of process improvement

Working Conditions & Travel Expectations

• Occasional evening conference calls not to exceed 3 calls per month
• Estimated travel not to exceed 10% to include survey participation and weekend meetings (i.e., attendance at governance meetings and education programs)

Physical Requirements

• Sedentary work: Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Salary varies based on experience, location, and qualifications