Associate Director of Risk and Compliance

Associate Director of Risk and Compliance

Associate Director of Risk and Compliance

CLASSIFICATION/STATUS: Full time (would consider part time hours for right candidate), Permanent
IMMEDIATE SUPERVISOR: COO
SUPERVISORY RESPONSIBILITIES: None
FLEXIBLE WORK OPTION: Hybrid (On-site 3-4 days per week)
SALARY BAND: Band 5 ($72,800 to $101,000 annual)

WHO YOU ARE
YOUR ROLE & IMPACT

Charles River Community Health’s mission is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them. The Associate Director of Risk and Compliance will lead compliance related functions and collaborate with other departments to support patient safety and minimize risk within the organization.

YOUR RESPONSBILITIES

• As the compliance expert for CRCH, provides education to CRCH leaders, staff and clinicians across all departments on the topics of compliance and risk management utilizing CRCH Med Trainer (an online educational tool) and other resources. Works with the Senior Leadership Team and managers to establish an annual risk and compliance training plan at the organizational and department level and ensures completion of all training.
• Carries out on-site compliance rounding along with periodic on-site shadowing of clinical services in all areas, as well as ongoing staff education and training to stay in compliance with evidence-based guidelines.
• Informs management of any incidents (and escalates significant incidents). Conducts investigations and root cause analysis to address individual risk incidents and recommend system changes to reduce risk going forward.
• Leads the organization in developing, updating and maintaining patient safety, risk and compliance, policies, procedures and objectives along with department subject matters, as needed.
• Ensures all policies are uploaded into the Med Trainer system. Must also keep an updated binder with all copies of current policies for any site visits.
• Leads and coordinates the validation of actual clinical and operations performance versus policy and procedures outlines. Assists departments to ensure the two are in alignment.
• Follows through on patient complaints and grievances to ensure they are resolved, as well as tracking them in the Med Trainer system. Reports on meaningful trends and insight to leadership.
• Responsible for staying current on Risk and Compliance regulations and making annual recommendations for updates to core training offerings for CRCH staff to take. Takes the lead in establishing and carrying out CRCH Annual Risk Management Training.
• Responsible for the ongoing CRCH wide accreditation status, directs self-assessment, site visit, and malpractice renewal process (FTCA application) as required by HRSA. On an annual basis, assesses, coordinates, and submits required HRSA items. Monitors action plans throughout the year for compliance.
• Takes the lead for the ongoing CRCH wide licensure and certification status, and directs the self-assessment, site visit and clinic licensure’s renewal process as required by the state Department of Public Health. Ensures compliance and maintenance of related certificates including CLIA for on-site laboratory services.
• Accountable for the ongoing CRCH Patient Centered Medical Home certification and is responsible for renewal. Works with clinical and operational leaders to ensure compliance and maintenance of related documentation
• Works in concert with VP of Operations, Chief Clinical Officer, Nursing, Clinical and Operational management, when necessary, in gathering and documenting information pertaining to all potential liability claims and high-risk areas.
• Assists senior management/leadership and directors in the coordination of on-site investigations by various external reviewers (i.e., DPH, CMS, HRSA).
• Assists senior management and directors in the implementation and ongoing measurement of various CRCH initiatives relating to patient safety, patient satisfaction, risk and compliance, and safety standards.
• Stays up to date on regulatory and external policy changes impacting CRCH and recommends policy and procedure…