Job Description

Job Description

Job Description

Quality & Risk Director-West Virginia

Salary Range: $111,000-$150,000

Relocation Assistance & Sign on bonus negotiable

300 licensed beds, acute care facility

People are our passion and purpose. Come to work where you are appreciated for who you are not just what you can do. The Hospital is a 300-bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services.

Where We Are:

This city is an ideal place to live and boasts many scenic, cultural, and recreational opportunities. From restaurants and breweries to art galleries and unique attractions, it is an outdoor playground with something for all tastes.

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.

Collaborate 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. Conduct 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, LLC 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.

Participate in review and development of committee structure and membership for facility.

Devises quality report cards for Physicians and Advanced Practice Practitioners

Regulatory Compliance

Oversee 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 participating 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.

Reports to: Chief Executive Officer

Must-Haves

• West Virginia license as a Registered Nurse required.
• Bachelor's in Nursing required
• Previous Quality experience required
• At least 5 years as an RN in acute care required

Nice-To-Haves

• CPHRM and CPPS ideal. Will be required within 2 years of employment.

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