Director of Risk and Compliance

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Regular Full-time Worcester, MA, US

Salary Range: $84,000.00 To $ Annually

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.

• 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.

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)
• 4.Program monitoring
• 5.HRSA reporting
• 6.Corrective Action Plans
• 7.Federal grant compliance

• 1.Coordinate HRSA Operational Site Visit preparation.
• 3.Lead corrective action implementation following HRSA reviews.
• 4.Ensure ongoing readiness for HRSA site visits.
• 5.Regulatory Compliance

• 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

• 1.Readiness assessments
• 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

• 1.Patient safety reporting
• 3.Failure Mode and Effects Analysis (FMEA)
• 5.Near miss reporting

• 2.Access to care
• 3.Care coordination

• 2.Clinical risk
• 4.Adverse event investigations
• 6.Medical record audits
• 8.Corrective action tracking

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

• 2.Access metrics
• 3.Financial quality indicators
• 4.Regulatory compliance indicators

Use data analytics to identify trends and recommend improvement strategies.

• 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)

• 1.Regulatory updates
• 4.Infection prevention
• 5.HRSA requirements
• 6.Quality Improvement methodology
• 7.HIPAA

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

• Bachelors in Nursing or Public Health and5 + years working in compliance and quality role

FQHC experience strongly preferred

HRSA experience strongly preferred

Reporting Relationship:
Chief Operating Officer