Hybrid Associate Director – Risk and Compliance

at Charles River Community Health

• Job title: Associate Director – Risk and Compliance
• Job type: Full Time
• Experience level: Senior
• Salary: $72,800 - $101,000 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Brighton, United States

About the role

• Associate Director of Risk and Compliance leading compliance-related functions in healthcare organization. Collaborating with departments to support patient safety and minimize risk.

Responsibilities

• 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 MedTrainer (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 MedTrainer 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 MedTrainer 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 licensures 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 changes to leadership for implementation.
• Chairs the Patient Safety Committee with the clinical directors to discuss safety events and incident reports.
• Supports clinical leadership in identifying training needs and in developing and delivering training on both compliance and non-compliance subject matter.
• Responsible for the Risk and Compliance introduction during New Hire Orientation.
• Works with clinical leadership to develop clinical workflows and polices that ensures the health center is/stays compliant.
• Assists the IT department in running monthly Electronic Health Record Audits of employee access.
• Works with managers and supervisors to ensure all staff are maintaining and following HIPAA guidelines and preserving patient confidentiality.
• Assists in identifying high-risk or complex patients in Epic and flagging any patients who have a history of being disruptive.
• Perform other duties as assigned by Chief Operating Officer or designee.

Requirements

• Bachelors degree in nursing, public health, health informatics, or related healthcare field preferred.
• Master's degree in healthcare related field preferred.
• Massachusetts nursing license or license in another clinical discipline preferred.
• Experience in Quality Improvement concepts and tools, Risk Management, Patient Safety, and nursing/clinical management required.
• Prior experience working with HRSA preferred.
• 5-10 years of strong healthcare experience required.
• Excellent written and verbal communication skills.
• Demonstrated clinical knowledge, as well as demonstrated knowledge of quality improvement, patient safety, peer review, and compliance.
• Capacity to use Word, Excel and Power Point to write reports, maintain spreadsheets, and create presentations required.
• Must have a willingness to work flexible hours to meet the organization's needs/demands.
• Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.
• Must have excellent communication skills, particularly with people from diverse cultures, with the ability to understand the community, population, and patients we serve.
• Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

Benefits

• Medical & Dental Insurance
• Short & Long-term Disability Insurance
• Generous Paid Time Off
• Flexible Spending Account
• Employee Assistance Program
• Tickets at Work
• Health Reimbursement Arrangement
• Travel Reimbursement
• Professional Development Opportunities
• Solid track record of developing and promoting employees internally!