Under the direction of the Chief Executive Officer (CEO) the Director, Risk Management/Accreditation is responsible for directing, organizing, leading, implementing and supervising day to day operations of the Risk Management, Accreditation/Regulatory Compliance and Infection Control efforts for two hospitals with a total of approximately 240 beds. The director serves as the hospital Patient Safety Officer and Compliance Officer.

Risk Management Program Administration:

· Serves as a resource to senior leadership, facility and medical staff. Participate in 24-hour call.

· Made aware of all serious incidents ensuring thorough investigations and notifications to senior leaders, and hospital risk as warranted.

· Reviews and updates the Risk Management Plan, Goals and Objectives yearly.

Risk Identification:

· Is responsible for maintaining the risk management database and notifies Sr. Director Corporate Risk Management and/or Corporate Group Risk Manager of all G. H. I incidents.

· Oversees and participates in facility risk assessments for clinical and non-clinical areas

· Participates in RCA’s and FEMA’s and ensures submission to Corporate Risk Management

· Participates in the peer review process and presents serious incidents, when applicable

Risk Management Education:

· Participates in the new employee orientation for discussion of the Risk Management Program, Patient Safety, incident reporting and TERM

· Acts as a resource for issues (i.e., consents, confidentiality, documentation, ethical, standard of care, compliance)

· Promotes Best Practices by educating facility and medical staff on risk management issues.

Risk Prevention Techniques:

· Participates in the development, implementation and review/revision of policies and procedures.

· Collaborates with clinical leaders to actively work and establish compliance with standards of care, best practices in industry accepted high-risk areas (i.e., ED, ICU, Surgery, OB, medication administration, fall prevention)

· Collaborates with the leadership team to promote positive patient/family/visitor experience.

· Works collaboratively with security and Human Resources to enforce facility safety practices (i.e. visitation, workplace violence, identification /harm prevention regarding patient belonging’s, and disclaimer for liability of vehicles parked on facility property

Measuring Effectiveness and Risk Management Program:

· Provides reports to Corporate Risk Management, as per established guidelines

· Complies and reports Midas RDE analysis and trends to appropriate individuals, departments and committee to be utilized for improvement of patient care

· Provides confidential reports of significant occurrences and incidents to applicable peer review committees and PSC

· Administration ensures the presentation of risk management information and reports are presented to the peer review committee by either the Director of Risk Management/Accreditation or the Director of Performance Improvement/Patient Engagement

Claims and Litigation Management:

· Directs and participates in the investigation of serious incidents concurrently with guidance from corporate risk management. Works with CBO regarding suspension of bills

· Timely forwarding of claim notices and submission of Probable Claim Reports

· Through administrative support develops and institutes policies and formalizes receipt of claims notices, securing evidence and confidentiality of information and material relating to claims.

· Concurrently informs Corporate Insurance ,Risk Management and Senior Facility Executives of attendance on any pending trials, mediations, or depositions and submits report of activity.

Requirements:

· Graduate of a state accredited school of nursing or graduate of an accredited collegiate program in a health-science related field.

· Master’s degree in a healthcare related field, or a Bachelor’s degree in related field with seven (7) years of director level experience; required

· At least four (4) years leadership experience in an acute care facility

· Certified Professional in Healthcare Risk Management of Certified Professional in Healthcare Quality
Expected Salary range 126,609 to $183,580 W relo and possible sign on bonus