Job Description

Position Summary:

The Director of Risk Management & Performance Improvement is responsible for planning, organizing, directing, and overseeing all risk management activities to ensure a safe environment for patients, employees, and visitors. This role ensures compliance with all relevant laws, regulations, and accreditation standards while implementing strategies to enhance patient safety, mitigate risks, and drive performance improvement initiatives across the facility.

Key Responsibilities:

Risk Management & Compliance:

• Investigate and analyze actual and potential risks, assessing liability and legal implications.
• Oversee and promote the facility-wide incident reporting system, ensuring timely and accurate documentation.
• Develop and implement risk management policies and procedures to align with industry best practices.
• Collaborate with internal auditors and security teams to establish and maintain internal control systems.
• Ensure compliance with regulatory requirements, accreditation standards, and institutional policies.
• Maintain a database of full disclosure activities and provide oversight for review programs.

Performance Improvement & Quality Assurance:

• Lead and coordinate the Quality Assurance/Process Improvement (QAPI) Program for the facility.
• Monitor program performance, analyze data trends, and identify areas for improvement.
• Work closely with department directors to support and oversee QAPI and risk management activities.
• Develop and implement systems that enhance patient care, employee safety, and overall organizational efficiency.

Collaboration & Leadership:

• Serve as a consultant and resource for risk management, performance improvement, policy development, and compliance initiatives.
• Partner with clinical leadership to prevent and mitigate clinical risks.
• Foster effective relationships with staff and management to ensure best practices are followed.
• Oversee staff management, including hiring, training, development, and performance evaluation.

Regulatory Compliance & Accreditation:

• Monitor and maintain compliance with all state licensure and accreditation requirements.
• Ensure adherence to policies related to patient rights, confidentiality, and full disclosure.
• Work with leadership to develop and implement policies that support institutional goals and patient safety initiatives.

Qualifications:

Education & Experience:

• Required: Bachelor’s degree in Risk Management, Business, Finance, or a related field.
• Preferred: Master’s degree in Health Information Management, Nursing, or a related field.
• Experience:
• Minimum 5 years in risk management.
• At least 1 year of supervisory experience required.

Certifications & Licenses:

• Required: CPR and de-escalation certification (training available upon hire).

May Be Required: First Aid certification (depending on state/facility requirements).

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