Director of Risk and Compliance

Position Summary: 

The Director of Risk & Compliance provides strategic leadership for the organization's Performance Improvement (PI), Regulatory Compliance, Accreditation, and Risk Management programs. This position ensures organizational compliance with HRSA Health Center Program requirements, federal and state regulations, and accreditation standards promoting a culture of continuous quality improvement across the organization.

The  Director partners with executive leadership, clinical leadership, operations, and department managers to improve enhance organizational performance, reduce risk, and ensure regulatory readiness. This person will work closely with the director of quality and nursing team as it relates to quality improvement, patient safety, and infection control. 

Program Specific Essential Duties and Responsibilities:

1.    Risk and Compliance Improvement Leadership

2.    Develop and implement the organization's Risk and Performance Improvement (PI) strategy.

3.    Lead organization-wide Risk and Compliance initiatives. 

4.    Oversee  compliance committees and multidisciplinary improvement teams.

5.    Promote a culture of continuous improvement throughout the organization.

HRSA Compliance:

Serve as organizational lead for compliance with HRSA Health Center Program requirements including:

1.    HRSA Health Center Program Compliance Manual

2.    Operational Site Visits (OSV)

3.    FTCA Risk Management requirements 

4.    Program monitoring

5.    HRSA reporting

6.    Corrective Action Plans

7.    Federal grant compliance

Responsibilities include:

1.    Coordinate HRSA Operational Site Visit preparation.

2.    Maintain documentation supporting compliance.

3.    Lead corrective action implementation following HRSA reviews.

4.    Ensure ongoing readiness for HRSA site visits.

5.    Regulatory Compliance

Ensure compliance with:

1.    CMS Conditions of Participation

2.    HIPAA

3.    DEA regulations

4.    CDC recommendations

5.    Massachusetts Department of Public Health regulations

6.    Federal and state healthcare regulations

7.    Accreditation

Lead accreditation activities including:

1.    Readiness assessments

2.    Mock surveys

3.    Policy review

4.    Staff education

5.    Survey coordination

6.    Corrective action planning

7.    Continuous accreditation readiness

8.    Works closely with Clinical Quality & Patient Safety teams 

Oversee:

1.    Patient safety reporting

2.    Root Cause Analyses (RCA)

3.    Failure Mode and Effects Analysis (FMEA)

4.    Sentinel event review

5.    Near miss reporting

Implement systems to improve:

1.    Patient outcomes

2.    Access to care

3.    Care coordination

4.    Patient experience

5.    Risk Management

Provide oversight for:

1.    Enterprise risk management

2.    Clinical risk

3.    Incident reporting

4.    Adverse event investigations

5.    Patient complaints

6.    Medical record audits

7.    Infection prevention collaboration

8.    Corrective action tracking

Partner with legal counsel and insurance carriers regarding risk mitigation activities.

Data Analytics & Performance Reporting

Develop dashboards that monitor:

1.    Patient satisfaction

2.    Access metrics

3.    Financial quality indicators

4.    Regulatory compliance indicators

Use data analytics to identify trends and recommend improvement strategies.

Policy & Procedure Management

1.    Develop and maintain organizational policies.

2.    Ensure policies reflect current federal and state regulations.

3.    Coordinate annual policy review.

4.    Monitor implementation and compliance.

5.    Staff Education

6.    Report to Board of Directors Policy and Procedure Committee (ss add)

Develop compliance education programs covering:

1.    Regulatory updates

2.    Patient safety

3.    Incident reporting

4.    Infection prevention

5.    HRSA requirements

6.    Quality Improvement methodology

7.    HIPAA

8.    Risk management

Qualifications and Education Requirements:

One of the following combinations of education and employment experience must be met in order to be considered for the position:

Education    And    Experience

Bachelors in Nursing or Public Health  and  5 + years working in compliance and quality role 

FQHC experience strongly preferred

HRSA experience strongly preferred 

Reporting Relationship: Chief Operating Officer

EOE