--- title: ASC Accreditation & Compliance Specialist LA/OC/IE/SD description: ASC Accreditation & Compliance Specialist LA/OC/IE/SD at EASTERN ORANGE AMBULATORY SURGERY CENTER. See the full description and apply. type: job url: https://www.foundrole.com/jobs/asc-accreditation-and-compliance-specialist-la-oc-ie-sd-at-eastern-orange-ambulatory-surgery-center-01a0b3c7-6b9e-76da-b943-3629d7118c64 date: 2026-11-15T01:26:44Z og_description: Join EASTERN ORANGE AMBULATORY SURGERY CENTER as ASC Accreditation & Compliance Specialist LA/OC/IE/SD in Santa Ana, CA. og_image: https://www.foundrole.com/og/529lni.png breadcrumbs: - label: Home url: https://www.foundrole.com/ - label: Search url: https://www.foundrole.com/jobs --- | | | |---|---| | **Company** | EASTERN ORANGE AMBULATORY SURGERY CENTER | | **Location** | Santa Ana, CA | | **Salary** | $82K/yr - $105K/yr | | **Type** | Full Time | | **Posted** | Oct 16, 2026 | ## Is this job real? **Ghost job check:** A- · Low risk. Probably a real opening. ## Visa sponsorship - **H-1B:** No H-1B sponsorship on record for EASTERN ORANGE AMBULATORY SURGERY CENTER. - **E-Verify:** No E-Verify enrollment on record for EASTERN ORANGE AMBULATORY SURGERY CENTER. ## Pay for similar jobs Most similar jobs pay $79,000 – $104,000 a year (median $87,000). ## 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 **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 ## Skills - Medication Management - Informed Consent - Credentialing - Investigation - Clinical Documentation - QAPI - Professional Documentation in Health Care - Internal Auditing - Surveys - Root Cause Analysis - Compliance Auditing - Basic Life Support - Survey Readiness - Gap Analysis - Memos - Document Review - Emergency Preparedness - Patient Safety - Sterilization - Content Management System (Cms) - Auditing - Microsoft Office - Infection Control - Corrective And Preventive Action (Capa) - Environment of Care - Leadership - Clinical Auditing - Advanced Cardiovascular Life Support (Acls) - Communication - Site Preparation - Governance - Provider Privileging - Patient Discharge - History and Physical Examination - Regulatory Compliance - Program Development ## Related - [Legal & Compliance jobs](https://www.foundrole.com/careers/legal-and-compliance?utm_source=ai_markdown)- [Compliance & Regulatory jobs](https://www.foundrole.com/careers/legal-and-compliance/compliance-and-regulatory?utm_source=ai_markdown)- [Compliance Officer / Analyst jobs](https://www.foundrole.com/careers/legal-and-compliance/compliance-and-regulatory/compliance-officer-analyst?utm_source=ai_markdown)- [Browse all companies](https://www.foundrole.com/companies?utm_source=ai_markdown) ## Related pages - [Hospitals and Health Care](https://www.foundrole.com/sectors/healthcare/hospitals-and-health-care?utm_source=ai_markdown) — 385444 jobs - [California](https://www.foundrole.com/locations/us/california?utm_source=ai_markdown) — 260754 jobs ## Browse - [Companies](https://www.foundrole.com/companies?utm_source=ai_markdown) - [Jobs by country](https://www.foundrole.com/locations?utm_source=ai_markdown) - [Jobs in the United States by state and city](https://www.foundrole.com/locations/us?utm_source=ai_markdown) - [H1B sponsors by location](https://www.foundrole.com/h1b-sponsors?utm_source=ai_markdown) - [H1B salaries](https://www.foundrole.com/h1b-salaries?utm_source=ai_markdown) - [Sectors and industries](https://www.foundrole.com/sectors?utm_source=ai_markdown) - [Jobs by career field](https://www.foundrole.com/careers?utm_source=ai_markdown) - [Latest jobs](https://www.foundrole.com/jobs/latest?utm_source=ai_markdown)