Job Description

Job Description

Job Description

JAC is currently assisting a 300-bed local hospital in West Virginia that is seeking to hire a Director of Quality and Risk Management. In this role, the leader will oversee, direct, and evaluate the activities, functions, and management of personnel within the Quality/Performance Improvement, Risk Management, and Medical Staff Office departments. Additionally, the leader will manage and achieve the fiscal goals defined for these departments. This position is responsible for ensuring facility-wide regulatory compliance and serves as both the Patient Safety Officer and the Ethics and Compliance Officer.

The leader will work to develop shared operational management among leadership, medical staff, and clinical employees to continually enhance patient care outcomes. They will implement the vision, goals, and strategies of the Senior Leadership team, acting as a dynamic leader with excellent communication skills, the ability to motivate others, and a commitment to advancing clinical practice and patient experiences.

Key responsibilities include collaborating with physicians, clinical managers, and other members of the healthcare team to coordinate activities between the hospital and physicians, promoting optimal patient care and service, identifying and resolving barriers, and encouraging growth in patient volume.

Additional responsibilities involve the oversight and continued implementation of the Ethics & Compliance Program, ensuring the facility's compliance with federal healthcare program requirements. The Director will conduct independent investigations into ethics and compliance issues and make sure that all ethics and compliance standards, policies, and procedures are communicated to each LifePoint colleague, agent, and independent contractor as per the requirements of their positions. They will create an environment where staff feel comfortable raising concerns or reporting suspected violations.

The Director will oversee the hospital-wide Quality and Performance Improvement program, including planning, organizing, and implementing performance improvement activities and Six Sigma team activities. They will provide ongoing education on performance improvement and Six Sigma processes, coordinate CMS/TJC Core Measures activities, and plan and organize the Regulatory and Accreditation program. This role will also serve as the contact person and liaison between the hospital and accreditation/regulatory agencies at both the federal and state levels.

In terms of ethics and compliance, the Director will serve as the Chair of the Facility Ethics & Compliance Committee, conduct investigations, encourage reporting without fear of retaliation, and advise colleagues on ethics and compliance matters. They will coordinate and support corporate monitoring and auditing procedures while establishing and maintaining formalized monitoring programs. The Director will identify trends related to ethics and compliance within the facility and communicate 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

Certifications :

Basic Life Support (BLS)

Required Licenses

CPHRM and CPPS are required or will be obtained within the first two years of employment. Maintains current license in profession.

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.

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