Director of Quality and Healthcare Risk

Director of Quality and Risk
Beckley, WV 25801

Reports to: Chief Executive Officer

Where We Are:
Beckley is an ideal place to live and boasts many scenic, cultural, and recreational opportunities. From restaurants and breweries to art galleries and unique attractions, Beckley is an outdoor playground with something for all tastes.

Who We Are:
A 300 bed facility caring for nearly 13,000 patients each year; we offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services.

Benefits offered:
Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
Competitive Paid Time Off / Extended Illness Bank package for full-time employees
Employee Assistance Program mental, physical, and financial wellness assistance
Educational assistance and tuition assistance for qualified applicants
Professional development opportunities and CE assistance
And much more

Position Summary:

Directs, controls and evaluates the activities, functions, and management of personnel within the Quality/Performance Improvement, Risk Management, and Medical Staff Office departments as well as effectively managing and meeting fiscal goals defined for these departments. Responsible for facility-wide regulatory compliance. Serves as the Patient Safety Officer and Ethics and Compliance Officer.
Achieves shared operational management among leadership, medical staff, and clinical employees to continually improve patient care outcomes.
Implements the vision, goals, and strategies of the Senior Leadership team as a dynamic leader with excellent communication skills and the ability to motivate and continually advance clinical practice and patient experiences.
Collaborates with physicians, clinical managers and other members of the health care team to coordinate activities between the hospital and physicians, promote optimum patient care/service, identify and resolve barriers, and promote growth in patient volume.
Oversight and continued implementation of the Ethics & Compliance Program and the facility's compliance with requirements of federal health care programs. Conducts independent investigations on ethics and compliance issues and ensures all E&C standards and policies and procedures are communicated to each colleague, agent and independent contractor according to the requirements of each position and then adhered to accordingly. Fosters and environment where colleagues know they can raise concerns or report suspected code violations.

Quality

Facility oversight of performance improvement program
Facility oversight of regulatory and accreditation program
Facility oversight of risk management program
Facility oversight of patient safety program
Leads the Quality/Risk/Medical Staff Office Department within defined financial priorities

Risk Management

Conducts clinical risk assessments and analysis of complex organizational systems within the facility and facilitates development of corrective action plan.
Formulates analysis plan for data management
Oversees investigations of incidents that could lead to professional/general liability claims.
Develops policies and procedures related to Risk Management.
Disseminates information and research related to changes in regulatory requirements and clinical research pertinent to potential liability exposures and risk issues
Consults with PSOrg on all occasions when the Hospital receives a request for dissemination of PSOrg related information, as well as other PSOrg compliance related issues.
Develops, implements and presents educational program for Employees, the Medical Staff and the Board
Obtains a minimum of 15 hours of continuing education in Risk Management on an annual basis.
Participates in review and development of committee structure and membership for facility.
Devises quality report cards for Physicians and Advanced Practice Practitioners

Regulatory Compliance
Oversees hospital-wide Quality and Performance Improvement program.
Plans, organizes and implements performance improvement activities
Plans and organizes Six Sigma team activities
Provides for ongoing education on PI and Six Sigma processes
Coordinates CMS/TJC Core Measures activities
Plans, organizes, and implements Regulatory and Accreditation program
Serves as contact person and liaison between the hospital and accreditation/regulatory agencies, both on a Federal and State level.

Ethics & Compliance
Serve as Chair for the Facility Ethics & Compliance Committee.
Conducting Investigations, encouraging Reporting without fear of retaliation and advising colleagues on E&C matters.
Coordinating and supporting Corporate monitoring and auditing procedures and establishing and maintaining formalized monitoring programs.
Identifying trends related to ethics and compliance within the facility and participate in communication and interfaces with Service Center ECOs, Corporate Departments and other ECOs.
Serving as liaison to the facility's Senior Administration and Department Directors.

Minimum Education

Bachelors degree - Required
Master's Degree - 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.

Certifications:
Basic Life Support (BLS)

Required Licenses
CPHRM and CPPS required or will obtain within first two years of employment. Maintains current license in profession.

Minimum Work Experience
Minimum 5 years health care experience preferred (clinical experience preferred). Minimum 2 years experience in clinical risk management preferred. Supervisor and/or management experience preferred.