Job Summary
The Director of Quality & Risk Management functions as the key hospital resource for performance improvement initiatives and activities and provides ongoing decision support to hospital leadership for hospital-wide operational improvement efforts. This position also functions as the facility Risk Manager. The risk manager is responsible for the management of a comprehensive health and safety/risk management program.
This position serves as the compliance officer and serves as the focal point for hospital compliance activities. This employee is responsible to ensure that the Board of Directors, management and employees are in compliance with the regulatory rules and regulations, that hospital corporate policy/procedures are being followed, and that behavior in the organization meets the hospital’s Standards of Conduct. Position requires access to highly confidential information.
Essential Job Functions
• Provides development, oversight, and support for the SHC Quality & Patient Safety program (Q&PS).
• Conducts data analysis and generates reports related to quality and safety.
• Conducts meetings and maintains minutes and other documentation for the Q&PS Committee.
• Provides initial orientation and ongoing education to employees, Medical Staff, and Board related to Quality, Safety, Performance Improvement and Risk Management.
• Provides development and oversight for a hospital-wide program of risk reduction and prevention.
• Maintains a system for investigation, trending and analysis of reported complaints, incidents, and claims to pinpoint areas requiring further problem resolution and/or specific risk management attention.
• Oversees the patient satisfaction and patient complaint processes.
• Works with the hospital liability insurance claims representative in investigation, evaluation, and management of open claims and/or potential claims. a
• Provides Medical Staff support for the Credentialing verification and Peer Review processes.
• Oversees, monitors, and coordinates, the SHC Compliance Plan.
• Monitors compliance through audits and other surveillance methods.
• Develops policies and procedures that encourage and allow personnel to report suspected compliance violations and other improprieties without fear of retaliation.
• Reviews contracts, financial arrangements, marketing initiatives, or other transactions for compliance with fraud and abuse laws and regulations.
• Provides compliance initial and ongoing education for hospital personnel. Works with department managers to establish appropriate internal compliance reviews and evaluation procedures.
• Prepare and submit periodic reports to the Board of Trustees on compliance activities, findings or audits and investigations. Make recommendations for corrective or remedial actions to address complaints or concerns.
• Maintains records and documentation of compliance reviews, findings, reports, and recommendations.
• Performs other duties as assigned.
• Degree or License in nursing or health related field required.
• Previous experience in hospital Quality & Patient Safety or Performance Improvement field preferred.
• Computer skills including Outlook, Word, and Excel required.
Skills/Competencies
• Leadership skills and ability to foster healthy interpersonal relationships.
• Excellent written and verbal communication skills.
• Excellent organizational skills with the ability to work independently in a fast-paced environment with attention to detail and prioritization.
