Director, Risk Management & Performance Impro

DEPARTMENT:      Risk Management

JOB CODE:            455                                                                            

REPORTS TO:        CEO/COO                                                            

POSITION TYPE:    Non-Direct Care                                         

FLSA STATUS:        Exempt         

PURPOSE STATEMENT:

Plan, organize, direct and control all aspects of risk management activities.  Ensure a safe environment for the protection of patients, clients, employees and visitors to the facility in such a manner as to comply with laws, regulations and the standards of the accrediting and approval agencies.

ESSENTIAL FUNCTIONS:

• Investigate and analyze actual and potential risks in the facility; assess liability and probability of legal action for potential notification. Implement, educate and encourage incident reporting system throughout the facility.
• Implement risk management program throughout the facility.
• Develop and implement infrastructures and systems that support patient safety.
• Work closely with Clinical Department practice to ensure the organization's procedures and policies are being followed by all employees.
• Work with internal auditors, security contractors, and other staff to establish an internal control system.
• Monitor and analyze program performance data to determine program effectiveness and identify opportunities for improvement.  Ensure compliance with all administrative requirements.
• Responsible for identifying high-risk areas that could cause harm to persons receiving services, visitors, and employees.
• Maintain database of full disclosure activities and provide oversight for review programs and provides technical support as needed.
• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.
• Serve as a resource and consultant for risk management activities, performance improvement, policy/procedure development and compliance initiatives.
• Collaborate with clinical staff and management for prevention of clinical risks throughout the facility. Develops effective working relationships with clinical staff and administrative personnel to facilitate the delivery of patient care.
• Create and implement policies and procedures that improve both patient care and employee safety. Ensure the application of institutional policies, especially those regarding patient rights, confidentiality and full disclosure.
• Develop, implement, coordinate and facilitates the Quality Assurance/Process Improvement (QAPI) Program for facility.
• Assess QAPI needs and trends for the facility program by reviewing current practices and gathering, compiling and evaluating data related to employees, services, and patient feedback.
• Delegate and support the QAPI and risk management activities of Department Directors to ensure desired, department-related outcomes for patient care and safety.
• Monitors and maintains compliance for accreditation for the facility.
• Monitors and maintains compliance for state licensure for the facility.

OTHER FUNCTIONS: 

• Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor's degree, risk management, business, finance, or a related field required.   Master's degree in health information management, nursing, or related field preferred.  
• Five or more years’ experience in a risk management position.  
• One or more years’ supervisory experience required.

LICENSES/DESIGNATIONS/CERTIFICATIONS: 

• CPR and de-escalation certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility.

ADDITIONAL REGULATORY REQUIREMENTS: