Risk Management / Performance Improvement Director

Position Summary

• Responsible for implementing and facilitating the company’s quality improvement and risk management programs at the facility.

• Identify opportunities to reduce risk exposure through review and analysis of data and direct observation of processes.

• Provide requirements related to laws, regulations, and standards of accreditation and approval agencies, including state licensure and The Joint Commission and/or CARF, to all staff and providers.

• Coordinates compliance activities with Bradford’s Chief Legal Officer and oversees implementation of related policies and procedures.

Non-Negotiable Hiring Criteria

• Bachelor’s or Associate’s degree in risk management, nursing or a related field.

• Two or more years experience in a risk management position.

• Demonstrated knowledge of laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of accreditation agencies as applicable to the facility licensure and accreditation status.

• Maintain appropriate professional boundaries and confidentiality, including a working knowledge of 45 CFR “Health Insurance Portability and Accountability Act” and 42 C.F.R. Part 2 “Confidentiality of Alcohol and Drug Abuse Patient Records” with respect to patient and potential patient identifying information and health information. This position has unrestricted access to identifying information and health information concerning patients, potential patients and participants.

• Ability to compile information into professional format for presentations and reports.

• Ability to work in a fast-paced environment, managing multiple responsibilities effectively.

Desired Qualifications

• One or more years supervisory experience.

• Skilled in utilizing Microsoft Office programs.

Primary Responsibilities

• Implement the Risk Management Program, including associated policies.
• Identify opportunities to reduce risk exposure through review and analysis of data and direct observation of processes.
• Report risk management data and issues to PIC and Bradford Risk Management leadership.
• Complete Detailed Incident Analysis (DIA) and Root Cause Analysis (RCA) when indicated by severity of incident.
• Review Incident Reports entered into the RiskQual system and identify severity level. Refer to Department Head for additional information as needed.

Primary Responsibilities – Performance Improvement

• Implement the Performance Improvement Program.
• Establish expectations, develop plans and manage processes to measure, assess, and improve the quality of the organization’s management, clinical and support activities.
• Measure, analyze and manage variation in the performance of defined processes that affect patient safety.
• Establish the agenda for the Performance Improvement Committee and coordinate with process owners regarding required reporting and follow-up.
• Provide quarterly Scorecard report to Bradford FMC.
• Enter Performance Improvement data into the facility shared drive spreadsheets as applicable.
• Coordinate the agenda and reports for Medical Staff meetings.
• Function as the point of contact with the survey team and/or Bradford Clinical, Risk and/or Compliance focused site visits.
• Facilitate Plans of Correction or Action Plans as a result of surveys and site visits.
• Develop, administer and oversee systems for ongoing regulatory compliance.