Director Quality & Risk Management

In addition to the responsibilities listed below, this position is also responsible for overseeing critical risk management projects such as cybersecurity, changes to the reimbursement structure, and the impacts of changes in medical science to hospital performance, among others; maintaining a culture of continuous learning and interest in critical risk management practices and industry changes; and implementing structure and making recommendations on new processes to monitor various employee and patient physiological and psychological safety health issues.

• Prepares individuals for growth opportunities and advancement; builds internal collaborative networks for self and others. Solicits and acts on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Demonstrates continuous learning; oversees the recruitment, selection, and development of talent; ensures performance management guidelines and expectations to achieve business needs. Stays up to date with organizational best practices, processes, benchmarks, and industry trends; shares best practices within and across teams. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact.
• Oversees the operation of multiple units within a department by identifying member and operational needs; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
• Serves as the subject matter expert for clinical quality improvement processes and regulations for regions, internal and external committees, and key stakeholders by\: providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation and advising on the current climate and potential changes which may have long term effects on business operations; proactively engaging in internal and external committees, projects, and relevant initiatives to implement change and to move QA initiatives forward, as well as to communicate to senior leadership on the various changes and rationale for change; fostering collaborative, results-oriented partnerships with practitioners, staff, management, and/or departments across clinical and administrative roles to ensure current and future compliance, and advising on changes to KP policy; defining the standards for educational programs to raise awareness for current and changing regulation requirements, internal concerns, and system/database usage; and identifying barriers to process improvement issues, weighing practical, technical, and KP capability considerations in addressing issues, and advising on policy changes.
• Directs the quality of care complaints and review process by\: directing and representing KP at grievance meetings, cases, reviews, referrals, and other mechanisms; responding to and directing the preparations of all documentation, records, and information requested for specific and highly sensitive patient case reviews; reporting trends in the process flow of investigations and claims for red flags, appeal reasons, and overturns, reporting results, and advising on strategic direction; and defining the standards for the surveillance of quality improvement metrics, cases, quality care incidents, and near misses according to established protocols to ensure equal/consistent application of KP policies.
• Oversees infection prevention and control programs to improve employee and patient safety by\: directing and prioritizing epidemiological investigations and simulations of significant clusters of infection or serious communicable disease concerns as a part of prevention, surveillance, and outbreak management; coordinating, developing, and maintaining significant outbreak containment protocols and efforts; and consulting with Administration on infection control implications of architectural design, renovation, and construction.
• Directs risk management efforts by\: defining the standards for corrective action plan for improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys across the organization; defining the standards for root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches; defining the standards for escalating high-risk issues and trends to appropriate entity for resolutions; and defining the standards for health outcome analysis to continuously monitor oversight effectiveness.
• Oversees patient safety programs and initiatives by\: directing significant event management and response to safety hazards, accidents, incidents, threats, and significant events; and collaborating with executive management and external personnel to develop patient care and satisfaction programs which aim to improve patient flow, clinical support, patient services, and seamless transition of care.
• Oversees development of new clinical quality improvement programs by\: maintaining relationships with key stakeholders, senior management, peers of other markets, and external stakeholders to set the standards for new program guidelines, metrics, and operational definitions of quality improvement, and ensuring the sustainability of the program; serving as a subject matter expert on a variety of health concepts, regulatory requirements, and change management principles to foster the development of programs that optimize clinical quality, safety, or health outcomes; and providing insight into KPs capability of realizing strategic opportunities to develop as a learning organization by advocating for the program and consulting with senior management, technology stakeholders, and external vendors.
• Oversees the systems, procedures, and forms to improve data management programs and utilizes data to monitor and improve performance of all worker and patient safety programs by\: defining the standards for the quality improvement monitoring agenda for the organization that includes all aspects of data management and analysis of trends and patterns of practice; directing the interpretation of statistical analysis for management of quality improvement evaluations; acting as a subject matter expert in interpreting and applying data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources into business practices and guide strategy; and presenting and advising on the application of reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) into specified formats for senior and executive internal and external stakeholders.
• Oversees regulatory audits and survey efforts within region by\: serving as the primary contact between applicable government, regulatory, vendors, and key stakeholders or onsite visits and evaluations; developing the processes for implementing the standards for audit documentation, information, reports, and tools throughout the auditing process; reviewing prepared audit documentation, information, and reports for ad hoc and complex auditing; and directing continuous survey readiness activities to maintain compliance with regulatory standards to adapt to changes in regulatory and KP requirements.
• Oversees the evaluations of the cost effectiveness, practicality, and appropriateness of medical care given to patients by\: determining the standards for case reviews; partnering with key stakeholders to ensure standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care are followed; resolving systematic concerns with current patient treatment plans to ensure patient needs are met in a timely manner; partnering with key executive internal and external stakeholders to drive the direction of policy to meet current and future population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others; and establishing the standards for the evaluation of previous patient cases to monitor utilization metrics (e.g., length of stay, type of treatment, and time of treatment) and advocating for their resolution with key stakeholders.

In addition to the responsibilities listed below, this position is also responsible for overseeing critical risk management projects such as cybersecurity, changes to the reimbursement structure, and the impacts of changes in medical science to hospital performance, among others; maintaining a culture of continuous learning and interest in critical risk management practices and industry changes; and implementing structure and making recommendations on new processes to monitor various employee and patient physiological and psychological safety health issues.

• Prepares individuals for growth opportunities and advancement; builds internal collaborative networks for self and others. Solicits and acts on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Demonstrates continuous learning; oversees the recruitment, selection, and development of talent; ensures performance management guidelines and expectations to achieve business needs. Stays up to date with organizational best practices, processes, benchmarks, and industry trends; shares best practices within and across teams. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact.
• Oversees the operation of multiple units within a department by identifying member and operational needs; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
• Serves as the subject matter expert for clinical quality improvement processes and regulations for regions, internal and external committees, and key stakeholders by\: providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation and advising on the current climate and potential changes which may have long term effects on business operations; proactively engaging in internal and external committees, projects, and relevant initiatives to implement change and to move QA initiatives forward, as well as to communicate to senior leadership on the various changes and rationale for change; fostering collaborative, results-oriented partnerships with practitioners, staff, management, and/or departments across clinical and administrative roles to ensure current and future compliance, and advising on changes to KP policy; defining the standards for educational programs to raise awareness for current and changing regulation requirements, internal concerns, and system/database usage; and identifying barriers to process improvement issues, weighing practical, technical, and KP capability considerations in addressing issues, and advising on policy changes.
• Directs the quality of care complaints and review process by\: directing and representing KP at grievance meetings, cases, reviews, referrals, and other mechanisms; responding to and directing the preparations of all documentation, records, and information requested for specific and highly sensitive patient case reviews; reporting trends in the process flow of investigations and claims for red flags, appeal reasons, and overturns, reporting results, and advising on strategic direction; and defining the standards for the surveillance of quality improvement metrics, cases, quality care incidents, and near misses according to established protocols to ensure equal/consistent application of KP policies.
• Oversees infection prevention and control programs to improve employee and patient safety by\: directing and prioritizing epidemiological investigations and simulations of significant clusters of infection or serious communicable disease concerns as a part of prevention, surveillance, and outbreak management; coordinating, developing, and maintaining significant outbreak containment protocols and efforts; and consulting with Administration on infection control implications of architectural design, renovation, and construction.
• Directs risk management efforts by\: defining the standards for corrective action plan for improvement identified through utilization review, clinical records audit, claim denials, patient satisfaction surveys, and auditing surveys across the organization; defining the standards for root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches; defining the standards for escalating high-risk issues and trends to appropriate entity for resolutions; and defining the standards for health outcome analysis to continuously monitor oversight effectiveness.
• Oversees patient safety programs and initiatives by\: directing significant event management and response to safety hazards, accidents, incidents, threats, and significant events; and collaborating with executive management and external personnel to develop patient care and satisfaction programs which aim to improve patient flow, clinical support, patient services, and seamless transition of care.
• Oversees development of new clinical quality improvement programs by\: maintaining relationships with key stakeholders, senior management, peers of other markets, and external stakeholders to set the standards for new program guidelines, metrics, and operational definitions of quality improvement, and ensuring the sustainability of the program; serving as a subject matter expert on a variety of health concepts, regulatory requirements, and change management principles to foster the development of programs that optimize clinical quality, safety, or health outcomes; and providing insight into KPs capability of realizing strategic opportunities to develop as a learning organization by advocating for the program and consulting with senior management, technology stakeholders, and external vendors.
• Oversees the systems, procedures, and forms to improve data management programs and utilizes data to monitor and improve performance of all worker and patient safety programs by\: defining the standards for the quality improvement monitoring agenda for the organization that includes all aspects of data management and analysis of trends and patterns of practice; directing the interpretation of statistical analysis for management of quality improvement evaluations; acting as a subject matter expert in interpreting and applying data from databases, vital statistics, hospital patient discharge data, claims, and other relevant health sources into business practices and guide strategy; and presenting and advising on the application of reports (e.g., infection control research, utilization reviews, population health needs analysis, patient satisfaction) into specified formats for senior and executive internal and external stakeholders.
• Oversees regulatory audits and survey efforts within region by\: serving as the primary contact between applicable government, regulatory, vendors, and key stakeholders or onsite visits and evaluations; developing the processes for implementing the standards for audit documentation, information, reports, and tools throughout the auditing process; reviewing prepared audit documentation, information, and reports for ad hoc and complex auditing; and directing continuous survey readiness activities to maintain compliance with regulatory standards to adapt to changes in regulatory and KP requirements.
• Oversees the evaluations of the cost effectiveness, practicality, and appropriateness of medical care given to patients by\: determining the standards for case reviews; partnering with key stakeholders to ensure standard operating procedures for treatment for specific medical codes to ensure equal and timely access to care are followed; resolving systematic concerns with current patient treatment plans to ensure patient needs are met in a timely manner; partnering with key executive internal and external stakeholders to drive the direction of policy to meet current and future population health needs, such as community health concerns, access to transportation, knowledge of rights, reducing no shows, and others; and establishing the standards for the evaluation of previous patient cases to monitor utilization metrics (e.g., length of stay, type of treatment, and time of treatment) and advocating for their resolution with key stakeholders.

• Minimum two (2) years of experience managing operational or project budgets.
• Minimum seven (7) years of experience in a leadership role with or without direct reports.
• Minimum five (5) years of experience with databases and spreadsheets.
• Minimum four (4) years of experience delivering training programs.
• Minimum seven (7) years of experience in clinical setting, health care administration, or a directly related field.
• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum seven (7) years of health care experience or a directly related field OR Minimum ten (10) years of experience in health care or a directly related field.

• Professional in Healthcare Risk Management Certificate within 24 months of hire OR Professional Healthcare Quality Certificate within 24 months of hire

• Knowledge, Skills, and Abilities (KSAs)\: Negotiation; Business Process Improvement; Risk Management; Compliance Management; Health Care Compliance; Health Care Policy; Health Care Data Analytics; Learning Measurement; Community Health; Health Care Coding; Consulting; Managing Diverse Relationships; Delegation; Development Planning; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles; Infection Control

• Minimum two (2) years of experience managing operational or project budgets.
• Minimum seven (7) years of experience in a leadership role with or without direct reports.
• Minimum five (5) years of experience with databases and spreadsheets.
• Minimum four (4) years of experience delivering training programs.
• Minimum seven (7) years of experience in clinical setting, health care administration, or a directly related field.
• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum seven (7) years of health care experience or a directly related field OR Minimum ten (10) years of experience in health care or a directly related field.

• Professional in Healthcare Risk Management Certificate within 24 months of hire OR Professional Healthcare Quality Certificate within 24 months of hire

• Knowledge, Skills, and Abilities (KSAs)\: Negotiation; Business Process Improvement; Risk Management; Compliance Management; Health Care Compliance; Health Care Policy; Health Care Data Analytics; Learning Measurement; Community Health; Health Care Coding; Consulting; Managing Diverse Relationships; Delegation; Development Planning; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement; Quality Assurance and Effectiveness; Evidence-Based Medicine Principles; Infection Control

• Certified Professional in Healthcare Risk Management (CPHRM).
• Health care clinical license from the practicing/applicable state (e.g., Registered Nurse (RN), Registered Pharmacist (RPh), Physical Therapist, Occupational Therapist, Speech Therapist, Social Worker).

• Certified Professional in Healthcare Risk Management (CPHRM).
• Health care clinical license from the practicing/applicable state (e.g., Registered Nurse (RN), Registered Pharmacist (RPh), Physical Therapist, Occupational Therapist, Speech Therapist, Social Worker).

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