Job Description

Director of Quality and Risk

Full-time, onsite
Negotiable Signing Bonus and Relocation
Location, Beckley, WV
Reports to: Chief Nursing Officer

Position Summary:

Directs, controls, and evaluates the activities, functions, and management of personnel within the Quality/Performance Improvement, Risk Management, and Medical Staff Office departments as well as effectively managing and meeting fiscal goals defined for these departments. Responsible for facility-wide regulatory compliance. Serves as the Patient Safety Officer and Ethics and Compliance Officer.

Achieves shared operational management among leadership, medical staff, and clinical employees to continually improve patient care outcomes.

Implements the vision, goals, and strategies of the Senior Leadership team as a dynamic leader with excellent communication skills and the ability to motivate and continually advance clinical practice and patient experiences.

Collaborates with physicians, clinical managers, and other members of the health care team to coordinate activities between the hospital and physicians, promote optimum patient care/service, identify and resolve barriers, and promote growth in patient volume.

Oversight and continued implementation of the Ethics & Compliance Program and the facility's compliance with requirements of federal health care programs. Conducts independent investigations on ethics and compliance issues and ensures all E&C standards and policies and procedures are communicated to each LifePoint colleague, agent, and independent contractor according to the requirements of each position and then adhered to accordingly. Fosters an environment where colleagues know they can raise concerns or report suspected code violations.

Quality

- Facility oversight of the performance improvement program
- Facility oversight of the regulatory and accreditation program
- Facility oversight of the risk management program
- Facility oversight of the patient safety program
- Leads the Quality/Risk/Medical Staff Office Department within defined financial priorities

Risk Management

- Conducts clinical risk assessments and analysis of complex organizational systems within the facility and facilitates the development of corrective action plans.
- Formulates analysis plans for data management
- Oversees investigations of incidents that could lead to professional/general liability claims.
- Develops policies and procedures related to Risk Management.
- Disseminates information and research related to changes in regulatory requirements and clinical research pertinent to potential liability exposures and risk issues
- Develops, implements, and presents educational programs for Employees, the Medical Staff, and the Board
- Obtains a minimum of 15 hours of continuing education in Risk Management on an annual basis.
- Participates in the review and development of committee structure and membership for the facility.
- Devises quality report cards for Physicians and Advanced Practice Practitioners

Regulatory Compliance

- Oversees hospital-wide Quality and Performance Improvement program.
- Plans, organizes, and implements performance improvement activities
- Plans and organizes Six Sigma team activities
- Provides for ongoing education on PI and Six Sigma processes
- Coordinates CMS/TJC Core Measures activities
- Plans, organizes, and implements the Regulatory and Accreditation program
- Serves as the contact person and liaison between the hospital and accreditation/regulatory agencies, both on a Federal and State level.

Ethics & Compliance

- Serve as Chair for the Facility Ethics & Compliance Committee.
- Conducting Investigations, encouraging Reporting without fear of retaliation, and advising colleagues on E&C matters.
- Coordinating and supporting Corporate monitoring and auditing procedures and establishing and maintaining formalized monitoring programs.
- Identifying trends related to ethics and compliance within the facility and participating in communication and interfaces with Service Center ECOs, Corporate Departments, and other ECOs.
- Serving as a liaison to the facility's Senior Administration and Department Directors.

Minimum Education
Bachelor’s degree - Required
Master's Degree - Preferred

Required Skills
Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.  

Certifications:
□ Basic Life Support (BLS)

Required Licenses
West Virginia, or (compact state license)
CPHRM and CPPS required or will obtain within the first two years of employment. Maintains a current license in the profession.

Minimum Work Experience
Minimum 5 years of health care experience preferred (clinical experience preferred). Minimum 2 years of experience in clinical risk management preferred. Supervisor and/or management experience preferred.

People are our passion and purpose. Come work where you are appreciated for who you are, not just what you can do. We are a 300-bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services.

Where We Are:
Located in the beautiful state of West Virginia, our facility offers a fantastic place to live and work. This region boasts numerous scenic, cultural, and recreational opportunities. From diverse restaurants and local breweries to art galleries and unique attractions, southern West Virginia is an outdoor enthusiast's dream with something to appeal to every interest. Enjoy a lower cost of living and a strong sense of community while being surrounded by natural beauty and accessible outdoor adventures.

Why Choose Us:
· Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
· Competitive Paid Time Off / Extended Illness Bank package for full-time employees
· Employee Assistance Program – mental, physical, and financial wellness assistance
· Educational assistance and tuition assistance for qualified applicants
· Professional development opportunities and CE assistance
· And much more…
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