Sr Quality & Compliance Spec

Rochester, NY


Responsible for supporting the implementation and operational oversight of the American College of Surgeon’s (ACS) Geriatric Surgery Verification (GSV) Program. Works closely with the Geriatric Surgery Director and the Geriatric Surgery Quality Committee (GSQC). Coordinate complaince with all aspects of the GSV program requirements, utilizing the ACS GSV Standards for guidance. Monitor compliance and facilitate performance improvement projects as opportunities are identified. In collaboration with Geriatric Surgery Director, is responsible to oversee the preparation for the American College of Surgeons GSV site visits.


  • Serve as main point of contact for ACS GSV Program

  • Assist Geriatric Surgery Director in developing and implementing plan to obtain ACS accreditation as a Geriatric Surgery Verified Hospital; including preparation for site visits

  • Oversees the day-to-day operations of the GSV Program, including compliance with “Optimal Resources for Geriatric Surgery”

  • Expert in geriatric surgical care and program management by maintaining up to date knowledge of clinical and regulatory guidance. Ongoing staff education (new teams and refreshers)

  • Serve as an internal resource for staff in all departments and acts as an extended liaison for all other URMC entities, the community, and national regulatory bodies.

  • Coordinates care across the continuum of geriatric surgical care including planning and implementation of evidence based clinical protocols, guidelines, and procedures.

  • Works in collaboration with ISD/Epic build team to develop EMR tools that support the GSV program.

  • Coordinates the Geriatric Surgery Quality Committee (GSQC) meetings including attendance and minutes

  • Document case reviews including recommendations from the Interdisciplinary Care for High-Risk Patient Conference

  • Implement plans of action from committee meetings

  • Monitor progress of improvement plans/interventions

  • Overseeing the annual QA/PI Projects and ongoing research projects.

  • Monitors geriatric surgical care and individual patients to ensure compliance with all GSV requirements. Direct communication with patients and potential frailty screening and care navigation

  • Coordinates and facilitates communication among the many disciplines that work in concert to provide high quality geriatric care.

  • Community outreach project

  • Works with the Quality Institute to develop program scorecard/dashboards.

  • Develops audits to ensure compliance with GSV Standards as outlined in the GSV Optimal Resources for Geriatric Surgery manual.

  • Distribute data to all stakeholders involved in geriatric surgical care.

  • Promotes and maintains collaborative relationships and open communication channels among all disciplines involved in geriatric surgical care.

Other projects and job duties as assigned



  • Bachelor’s degree in health-related field including Registered Nurse or Public Health

  • Master’s degree preferred

  • Minimum of 5 years’ relevant experience in acute care hospital with surgical/geriatric specialty including 2 years managerial level preferred or equivalent combination of education and experience.


  • Detail oriented with strong organizational/prioritization skills and ability to work independently under general guidance.

  • Proficiency in Microsoft Office (Word, Excel, PowerPoint), software/web applications, and electronic medical record. REDCap experience preferred.

  • Experience with ACS Verification Programs, data management, and quality improvement activities in an Academic Medical Center desirable.

  • High degree of emotional maturity that enables successful interactions with adverse constituency and that facilities group problem solving.

  • Excellent negotiations skills successfully applied to change management and conflict resolution.

  • Well-developed critical thinking and analytical skills.

  • Excellent communication skills involving written, spoken, and presentation abilities that can be modified for all levels of skilled and unskilled team members.

  • Independent worker accustomed to clear accountability and reporting.

  • Proven managerial skills that demonstrate an ability to develop high-functioning teams, lead change, and facilitate interdisciplinary collaboration.

  • High level of organizational skills to manage projects, timetables, and implementation plans.

  • Advanced interpersonal skills to develop effective teams and manage/direct/coordinate team activities.

  • Ability to influence and motivate collaborators.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $68,765 - $103,147 Annually

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time