Director of Risk and Compliance

Position Summary

The Director of Risk & Compliance provides strategic leadership for the organization's Performance Improvement (PI), Regulatory Compliance, Accreditation, and Risk Management programs. This position ensures organizational compliance with HRSA Health Center Program requirements, federal and state regulations, and accreditation standards promoting a culture of continuous quality improvement across the organization.

The Director partners with executive leadership, clinical leadership, operations, and department managers to improve enhance organizational performance, reduce risk, and ensure regulatory readiness. This person will work closely with the director of quality and nursing team as it relates to quality improvement, patient safety, and infection control.

Program Specific Essential Duties and Responsibilities:

1. Risk and Compliance Improvement Leadership
2. Develop and implement the organization's Risk and Performance Improvement (PI) strategy.
3. Lead organization-wide Risk and Compliance initiatives.
4. Oversee compliance committees and multidisciplinary improvement teams.
5. Promote a culture of continuous improvement throughout the organization. HRSA Compliance: Serve as organizational lead for compliance with HRSA Health Center Program requirements including:
6. HRSA Health Center Program Compliance Manual
7. Operational Site Visits (OSV)
8. FTCA Risk Management requirements
9. Program monitoring
10. HRSA reporting
11. Corrective Action Plans
12. Federal grant compliance Responsibilities include:
13. Coordinate HRSA Operational Site Visit preparation.
14. Maintain documentation supporting compliance.
15. Lead corrective action implementation following HRSA reviews.
16. Ensure ongoing readiness for HRSA site visits.
17. Regulatory Compliance Ensure compliance with:
18. CMS Conditions of Participation
19. HIPAA
20. DEA regulations
21. CDC recommendations
22. Massachusetts Department of Public Health regulations
23. Federal and state healthcare regulations
24. Accreditation Lead accreditation activities including:
25. Readiness assessments
26. Mock surveys
27. Policy review
28. Staff education
29. Survey coordination
30. Corrective action planning
31. Continuous accreditation readiness
32. Works closely with Clinical Quality & Patient Safety teams Oversee:
33. Patient safety reporting
34. Root Cause Analyses (RCA)
35. Failure Mode and Effects Analysis (FMEA)
36. Sentinel event review
37. Near miss reporting Implement systems to improve:
38. Patient outcomes
39. Access to care
40. Care coordination
41. Patient experience
42. Risk Management Provide oversight for:
43. Enterprise risk management
44. Clinical risk
45. Incident reporting
46. Adverse event investigations
47. Patient complaints
48. Medical record audits
49. Infection prevention collaboration
50. Corrective action tracking Partner with legal counsel and insurance carriers regarding risk mitigation activities. Data Analytics & Performance Reporting Develop dashboards that monitor:
51. Patient satisfaction
52. Access metrics
53. Financial quality indicators
54. Regulatory compliance indicators Use data analytics to identify trends and recommend improvement strategies. Policy & Procedure Management
55. Develop and maintain organizational policies.
56. Ensure policies reflect current federal and state regulations.
57. Coordinate annual policy review.
58. Monitor implementation and compliance.
59. Staff Education
60. Report to Board of Directors Policy and Procedure Committee (ss add) Develop compliance education programs covering:
61. Regulatory updates
62. Patient safety
63. Incident reporting
64. Infection prevention
65. HRSA requirements
66. Quality Improvement methodology
67. HIPAA
68. Risk management Qualifications and Education Requirements: One of the following combinations of education and employment experience must be met in order to be considered for the position: Education And Experience Bachelors in Nursing or Public Health and 5 + years working in compliance and quality role FQHC experience strongly preferred HRSA experience strongly preferred Reporting Relationship: Chief Operating Officer EOE Monday

• Friday; 8:30am -5:00pm.