Director, Clinical Risk Management & Regulatory Affairs

Job Category Management

Schedule Full time

Shift 1 - Day Shift

The Director, Clinical Risk Management & Regulatory Affairs provides strategic and operational leadership for the health system's clinical risk management, regulatory readiness, accreditation, and risk mitigation programs. The Director establishes an integrated approach for identifying, evaluating, reducing, and monitoring organizational risk while supporting compliance with applicable federal, state, accreditation, licensing, and reporting requirements.

As a trusted advisor to executive leadership, medical staff, nursing, legal counsel, and operational leaders, the Director interprets regulatory expectations, coordinates responses to inquiries and surveys, oversees clinical risk review and claims-related activities, and promotes reliable systems that protect patients, team members, and the organization. The Director leads a multidisciplinary team and supports transparent, timely escalation of significant risk and compliance concerns.

• Develop and execute an enterprise clinical risk management and regulatory affairs strategy aligned with organizational priorities.
• Advise leaders on material clinical, operational, regulatory, and accreditation risks and recommended mitigation actions.
• Establish methods for risk identification, prioritization, escalation, monitoring, and closure.
• Promote a proactive, systems-based approach to reducing liability exposure and regulatory risk.

• Direct the clinical risk management program across inpatient, ambulatory, and other designated care settings.
• Lead efforts to reduce serious safety events and preventable harm.
• Oversee review and investigation of events with potential liability, regulatory, or reputational implications.
• Evaluate trends and recommend controls, process changes, education, or other actions to lessen risk.
• Partner with Patient Safety and operational leaders to ensure coordinated review without unnecessary duplication.
• Provide consultation regarding disclosure, documentation, preservation of information, and risk-sensitive communications in collaboration with Legal Services.

• Oversee, facilitate, and assist with event review sessions, including Root Cause Analyses, Action Plan reviews, safety debriefs, hot washes, and learning reviews, as indicated.
• Ensure corrective actions are specific, measurable, implemented, monitored, and sustained.
• Establish processes to spread lessons learned across the health system.
• Use systems-based methods to identify vulnerabilities and strengthen barriers and controls.

• Coordinate timely notification, documentation, review, and follow-up for claims and potential claims in partnership with legal counsel and insurers.
• Support fact development, record preservation, case review, and organizational response activities.
• Monitor claims themes and collaborate with leaders on targeted risk-reduction strategies.
• Maintain appropriate confidentiality and legal protections for sensitive risk-management information.

• Maintain continuous readiness for applicable accreditation surveys, government reviews, licensing activities, and regulatory inquiries.
• Monitor, interpret, and communicate changes in regulatory and accreditation requirements.
• Coordinate organizational assessment, readiness planning, evidence collection, survey support, and corrective-action response.
• Ensure regulatory commitments, plans of correction, and follow-up actions are assigned, monitored, validated, and closed.
• Serve as an organizational liaison with…