Director of Quality, Risk Management, and Compliance
Westborough Behavioral Healthcare Hospital
- Westborough, MA
- $126,692-199,700 per year
- Permanent
- Full-time
- Serves as hospital’s subject matter expert for regulatory standards including: Joint Commission, CMS conditions of participation, DHM licensing regulations for inpatient/outpatient psychiatric services.
- Maintains a system of continuous survey readiness, staff education, internal audits, and policy/procedure reviews.
- Ensures timely completion, implementation and submission of all necessary corrective action plans.
- Develops and maintains compliance tracking systems to monitor performance against regulatory requirements. Drafts, reviews, and oversees hospital policies, procedures, and protocols to ensure alignment with all applicable standards and regulations.
- Leads the Quality Assurance and Performance Improvement Committee as well as Patient Safety and Workplace Violence Prevention committee and drives strategies related to the design and continuous improvement of the QAPI plan and to improve the safety culture across the hospital.
- Develops and implements reporting infrastructures and ensures integrity of internal and external reporting.
- Collaborates closely with all department leaders and works seamlessly to communicate critical information at all levels - from frontline staff to senior leadership. Leads the execution of education and training to staff, improvement opportunities and initiatives through both formal and informal venues.
- Serves as both the HIPAA and Compliance Officer to establish and maintain policies, procedures, and practices to ensure the facility operates ethically and in compliance with all Federal and State Health Insurance Portability and Accountability Act (HIPAA) and all other relevant state and federal laws, regulations and professional standards.
- Develops and oversees the hospitals Risk Management Program, including incident reporting, investigation, and analysis.
- Collaborates with QAPI disciplines to complete a Root Cause Analysis for specified events and Failure Mode and Effects Analyses (FMEA) as required.
- Monitors trends in adverse events, complaints, and near misses; identify opportunities for system improvements.
- Ensures timely reporting of sentinel events, critical incidents, and other required notifications to regulatory agencies.
- Collaborates with leadership and legal team on insurance liability claims, and contract reviews from a compliance and risk perspective.
- Prepares reports for leadership, the Quality Committee, corporate office on compliance, risk, and safety performance.
- Oversees the Human Rights officer, reviews complaints and grievances to ensure appropriate resolution and identifies potential exposures.
- Support the hospitals Performance Improvement Plan (PIP)
- Ensure risk management and compliance data are integrated into QI reporting
- Monitor and analyze CMS quality reporting measures and Joint Commission quality indicators applicable to behavioral health.
- Promote a culture of accountability, transparency, and continuous improvement.
- 401K
- Health Insurance
- Dental and Vision Insurance
- Health Savings Account
- Employee Discount Program
- Employee Assistance Program
- Pet Insurance
- Paid Time Off
- Tuition Reimbursement
- Generous Associate Discounts