DEPARTMENT: Risk Management JOB CODE: 455 REPORTS TO:CEO 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. - Formulates facility policies and implements risk management program in conjunction with facility leadership. - 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 include 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 facilitate the Quality Assurance/Process Improvement (QAPI) Program for facility, including preparedness strategies. - Generates quality assurance reporting data, as assigned, for purposes of performance improvement and accreditation activities. - 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. - Demonstrates knowledge and compliance of regulatory/accreditation requirements and is responsible for facility preparedness to meet accreditation and licensing requirements. - Assists in development and implementation of evidence of standard compliance for licensure and accreditation activities. - Under the direction of the facility CEO, conducts reporting to external entities for the purpose of state licensure and accreditation. - Serves on facility committees such as Safety Committee, Leadership Committee, Performance Improvement Committee, and others as assigned. - Monitors and maintains compliance for accreditation and state licensure for the facility. - Implements and manages the occurrence reporting procedure and safety initiatives. - Evaluates and responds to grievances according to organizational procedure. - Devises, analyzes and/or performs documentation audits. - Creates and improves education/training to staff related to patient safety, documentation of services, licensure/accreditation requirements, and risk management. - Monitors completion of training assignments related to licensure/accreditation requirements, job competencies and/or annual compliance training. - Assists with the implementation and/or performance of activities related to the compliance program, as directed by the Chief Compliance Officer

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelors degree in risk management, business, finance, or related field. Masters degree in health information management or related field preferred.
• Minimum of five years experience in a risk management position.
• Minimum of one year in the field in a supervisory position.
• Demonstrate excellent communication (written and verbal) skills required.
• Comfortable working with the public.

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

Apply by completing the online application at https://bradfordhealth.com/careers.