Director of PI and Risk Management
2 days ago
DeSoto
Job Description The Risk Management/Performance Improvement Director is in charge of ensuring that the hospital follows all Joint Commission, CMS, and other regulatory bodies' standards and mandates at all times. This Director will be lead for investigations and point of contact for regulatory bodies, providing documentation and reports in response to inquiries. The position is also is in charge of overseeing and communicating the hospital's performance programs and metrics, such as outcome measurement and reporting. Essentiial Duties include: • Oversees surveys, abuse/neglect investigations, grievance follow-up, and sentinel event follow-up., • Analyzes and classifies incident reports and special treatment procedures at various levels of care and programs, providing recommendations and guidance to address and reduce risk., • Coordinates compliance operations and performance improvement actions in coordination with managers and department leaders. Establishes and maintain effective working relationships with physicians and health professional affiliates, patient's facilities, and staff., • Directly or collaboratively involved in department staff training, counseling, disciplinary, and evaluative actions., • Acts as a liaison with the corporate office on compliance issues, point of contact with licensing agencies and, when needed, with external entities (i.e. health department)., • Interprets, and implements practices related to federal, state, local regulations and licensing standards., • Leads the Risk Management and Performance Improvement Committees., • Carries out personnel management activities associated with direct staff supervision, including screening and selection, orientation training and development, performance management, and employee relations functions., • Participates in activities which enhance professional growth and development; maintains real-time knowledge of regulatory developments., • Performs audits (including detailed audits of patient medical records)., • Creates reports based on audit results., • Maintains a working knowledge of Federal and State laws, regulations and policies., • Participates in meetings/training as assigned or requested. Education & Training - Bachelor’s degree in a healthcare-related field or equivalent experience. Master’s degree in a healthcare-related field preferred. Training in healthcare compliance activities, healthcare safety/risk management, hospital performance improvement activities and hospital administration preferred. Experience – A minimum of three years of experience in a healthcare facility serving children, adolescents, adults and/or geriatric population with specific experience with compliance, JC standards, risk management, and performance improvement initiatives is required. Supervisory experience preferred. Required Licenses – Certified Professional in Healthcare Quality (CPHQ), or Certified Professional in Healthcare Risk Management (CPHRM) preferred. Texas Nurse or therapist license a plus. Knowledge Skills and Abilities • Must have basic PC skills that include a combination of working in a Windows Operating System and Microsoft Outlook, Word and Excel., • Ability to accurately enter data, and prepare and maintain records, files, and reports., • Able to work collaboratively, diplomatically, and with integrity in problem identification, project management, and problem-solving activities., • Quality Improvement methodology; organizational and time management skills; skills in data collection, analysis, evaluation, and interpretation; knowledge of applicable standards and regulations; problem-solving skills; teaching or training skills., • Is knowledgeable about healthcare risk management and performance improvement activities., • Displays knowledge of ethical principles and compliance issues in a healthcare setting. Is familiar with various types of documentation maintained in a healthcare setting., • Demonstrates a basic understanding of medical terminology., • Can work independently and productively with little supervision., • Requires leadership, organizational, supervisory, and administrative abilities., • Ability to effectively communicate and interact with interdisciplinary treatment teams., • Can develop action plans, coordinate resources, and see tasks through to completion., • Displays good organizational skills with outstanding skills in giving attention to detail., • Ability to maintain confidentiality when dealing with highly sensitive information., • Communicate effectively with a variety of individuals and function calmly in situations, which require a high degree of sensitivity, tact, and diplomacy., • Ability to exercise appropriate judgment in answering questions and releasing information; analyze and project consequences of decisions and/or recommendations., • Skill to independently interpret reference materials to comply with law, rules, regulations, policies, and procedures., • Ability to apply time management practices to prioritize, schedule, and complete work effectively to comply with mandated policies and deadlines. With or without reasonable accommodations, must be able to stoop, kneel, crouch, reach, stand for a sustained period of time, walk, pull, lift, raise and move objects from position to position (up to 50 lbs.), finger grasp; feel sizes, shapes, temperatures, and textures; express or exchange ideas orally and potentially loudly, accurately, or quickly; visually detect, determine, perceive, identify, recognize, judge, observe, inspect, assess; perceive the nature of sound with or without correction; perform repetitive motions of the wrist, hands, or fingers. Light work most of the time, exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently; and occasionally medium work, that is exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently. Ability to stoop, kneel, lift moving about in the work area and throughout the organization to accomplish tasks. Typing, data entry (finger dexterity), and ability to hold hands steady on a keyboard when typing. Sit for extended period of time of up to 8 hours with erect posture, reading forms/computer screens. Ability to clearly and concisely express and exchange ideas via the spoken word, conveying detailed information to others accurately and on occasion, quickly for up to 8 hours. Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly for up to 8 hours. Hearing: Perceiving the nature of sounds with no less than a 40 db loss @ 1000 Hz and 2000 Hz with or without correction. Ability to receive detailed information through oral communication and to make fine discriminations in sound for up to 8 hours. Sedentary Work: Exerting up to 10 to 15 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects for up to 8 hours. Visual Acuity: To inspect and analyze figures, accounting items, written materials, newsprint, computer terminal characters, transcription, and other similar objects at distances generally close to the eyes. This is a minimum standard based on the criteria of accuracy and neatness of work for up to 8 hours. The worker is subject to inside environmental conditions: Protection from weather conditions but not necessarily from temperature changes for up to 8 hours. Benefits Full-time employees are eligible for medical, dental, vision, company paid disability, 401(k) and a generous amount of paid time off.