Director of Quality and Risk Management

Welcome to Grace HealthPros, LLC

A resource for Healthcare Professionals, Hospitals and Healthcare Systems who share in a common vision of “providing the best Healthcare” for all patients.

JOB SUMMARY

Directs the activities and resources for the Quality Management department to achieve departmental and organizational objectives. Responsible for the facilities’ risk management activities, which include, but may not be limited to: a general knowledge of facility insurance programs; administering the risk management program on a day-to-day basis; managing and analyzing risk management data, trending, identifying gaps in results or program aspects, identifying opportunities for improvement, preparing reports to communicate data findings and analysis of information; conducting education applicable to risk management and patient safety initiatives; complying with regulatory and accreditation standards; formulating policy to support risk management initiatives and principles; participating in committees to integrate risk management into committee work product; interfacing with the corporate risk management department on claims management; and minimizing loss to protect the assets of the facility. Responsible for reviewing and formulating policy or organizational changes and making recommendations for approval by senior management. This position management and provides oversight for accreditation surveys.

Minimum Education

Bachelor’s degree in Nursing - Required

Master's degree in Nursing or Business/Healthcare related field - Preferred

Certification in Risk Management through a nationally recognized program meeting industry standards - Preferred

Required Skills

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Computer skills required. Strong understanding of: Process Review; Root Cause Analysis; Department of Health and Joint Commission requirements familiarity.

Basic Life Support (BLS) American Heart Association must be obtained within 90 days of employment, if not current upon hire

License: Current KY or Multi-State RN licensure. CPHQ certification required within 1 year of employment

Minimum Work Experience

· Five (5) years of healthcare experience as RN and two years’ experience in quality/clinical nursing leadership. - Preferred

· Five (5) years of experience in healthcare risk management and accreditation. Experience in the insurance industry is supportive to the skill set of the risk manager. - Preferred

· Three (3) years of experience in direct patient care with some experience in critical care. - Preferred

ESSENTIAL FUNCTIONS

· Develops and implements departmental goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization.

· Directs and evaluates departmental operations, including patient care delivery, information technologies, service level determination, and complaint management, to achieve performance and quality control objectives.

· Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary actions, and continuing education initiatives.

· Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates incompliance with allocated funding. Coordinates and directs internal/external audits.

· Creates and fosters an environment that encourages professional growth.

· Integrates evidence-based practices into operations and clinical protocols.

· Provides prompt notification to appropriate parties upon receipt of claim or lawsuit. Assist HSC Risk, leadership and external counsel in defense of the claims as instructed.

· Provides leadership, counsel, and support in areas of Risk Management

· Escalates significant risk issues with urgency

· Collaborates with site patient safety/quality improvement and patient experience leadership to respond to patient grievances. Uses decision making ability to analyze and recommend disposition strategies. Oversee and direct occurrence reporting process for site. Ensures timely data entry of reports received. Completes necessary trend analysis of occurrence reports

· Collects data for risk exposures and provides feedback to the involved departments. Ensure identified risk management strategies are undertaken by affected areas.

· Develops a safety culture where reporting is encouraged and use of SIM reporting system is monitored, with interventions to address issues as needed.

· Provide in-service education on risk management topics, both standard basic education and complex focused topics as needed and/or requested

· Provide statistical analysis for review by appropriate committees as requested.

· Create and implement new programs to foster a culture of safety and safe environment for patients, visitors, and staff.

· Coordinate and oversee the development of comprehensive accreditation improvement initiatives to establish compliance with regulatory agencies.

· Coordinate and ensure the implementation of organization-wide regulatory compliance activities with The Joint Commission, CMS, and other regulatory agencies.

· Facilitates the development of ongoing readiness action plans, assessments, and educational activities as appropriate.

· Utilizing the standards and regulations from CMS and TJC, oversees concurrent monitors to determine if staff knowledge and clinical practice meet appropriate standards.

· Coordinates risk reduction activity in the physical environment as specified within each Environment of Care(EOC) Management Plan.

· Facilitate the organization’s Regulatory Committee.

· Participates in interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions with the multidisciplinary team and appropriate service line leaders and directors.

NONESSENTIAL FUNCTIONS

· Performs other duties as assigned

· I understand that it is my responsibility to know, understand and adhere to the following: Our Mission and Vision, Code of Conduct, LifePoint Core Values, Professional Appearance Standards

LEADERSHIP CAPABILITIES

· Effective Staff Management/Cultivate Success in Staff Professional Integrity

· Lead by Example

· Maintain Accountability Standards

· Ability to Understand Financial Functions and Be Fiscally Responsible

· Strategic Planning and Program Development Skills

· Adaptable to Growth and Change

· Communicate Effectively to Build Positive Relationships.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran

Feel free to call Carrie Taylor 978-505-0331

Check out our website www.gracehealthpros.com

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person