Job Description

Chiricahua Community Health Centers, Inc.

Job Title: Corporate Compliance & Risk Manager

Reports To: Chief Administrative Officer

Job Summary: Ensures organizational compliance with all applicable laws, rules, and regulations, and that company policies and procedures are being followed. Performs clinical risk management.

Qualifications and Requirements:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. This job description in no way implies that these are the only duties to be performed and may be modified, interpreted and/or applied in any way as necessary. Maintaining regular and punctual attendance is required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Essential Job Duties:

 Oversees Corporate Compliance Plan and Activities

  • • Reviews and revises CCHCI corporate compliance plan as needed.
  • • Studies existing and new legislation, anticipated future legislation and informs CCHCI leadership of pending regulatory changes.
  • • Oversees, develops and provides compliance training and serves as a resource for all staff.
  • • Collaborates with other departments and CCHCI leadership to perform internal compliance audits or monitoring activities and investigates and resolves compliance issues.
  • • Consults with attorneys and other resources as needed to resolve difficult legal compliance issues.
  • • Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
  • • Provides direction and management of the compliance Hotline.
  • • Coordinates policy and procedure development and implementation for all departments.
  • • Facilitates and assists with FTCA and HRSA compliance.
  • • Coordinates and assists with the State Licensure process.

 Provides Risk Management Leadership

  • • Evaluates areas of organizational risk based on internal assessment and external benchmarking and implements strategies and policies that promote patient and staff safety.
  • • Promotes occurrence reporting process including trending and reporting of results, identification of problem prone areas, and facilitation of prevention initiatives.
  • • Directs the investigation of all potentially compensable events (preventable adverse events).
  • • Leads the review of serious occurrences requiring root-cause analysis or failure mode and effects analysis.
  • • Disseminates lessons learned and process improvement plans.
  • • Meets regularly with leadership to provide detailed reports on serious incidents, claims, and risk-related issues.
  • • Responds to sentinel events and other serious occurrences and provides expert advice on the management and reporting of such events to administrative and clinical leadership and staff.
  • • Conducts immediate/appropriate response to any serious occurrence/complaint representing actual or potential patient, visitor, or employee injury. Monitors and takes subsequent actions to ensure learning, compliance, and documentation.
  • • Analyzes all statistical reports and advisories that identify risk management and patient safety patterns and trends for leadership.
  • • Ensures maximum protection from discovery of all claims/potential claims materials. Coordinates claims investigation and legal defense processes.
  • • Serves as liaison to external regulatory agencies for purposes of patient and physician reporting, event investigation, and response.
  • • Reviews and evaluates risk management-related policies and procedures and recommends revisions. Creates new policies for approval, as needed.
  • • Actively participates in a variety of committees as assigned.
  • • Evaluates risk management and patient safety program for improvement opportunities on an annual basis.

Chiricahua Community Health Centers, Inc.

 Provides Infection Control Leadership

  • • Evaluates and implements infection prevention and control measures in health centers.
  • • Recommends, implements and monitors policies and procedures for health center staff regarding sterilization, disinfection and decontamination of personnel, instruments and equipment.
  • • Provides training on infection control measures to all clinical staff.

 Promotes Staff and Patient Safety

  • • Establishes and participates in inter-departmental safety committee in order to coordinate safety efforts.
  • • Regularly reviews OSHA compliance, employee and patient safety policies and procedures.
  • • Develops and implements employee safety trainings and serves as a resource for safety efforts throughout the organization.
  • • Assists with patient safety efforts and maintains internal incident report files.
  • • Reviews workers compensation claims and recommends appropriate corrective actions.
  • • Coordinates safety reviews.

Required Education, Experience, Certificates & Licenses:

  • • Bachelor’s degree in health care management, public health, nursing, or a closely related field. Master’s Degree preferred.
  • • 3-5 years of progressively responsible experience in a health care setting, with preference for experience in a Federally Qualified Health Center.
  • • Experience in Community Health/Public Health with a clinical background preferred.
  • • Any combination of education and/or experience that provides the necessary skills and sensitivity.
  • • Completion of Ambulatory Care Risk Management Certificate Program (ECRI Institute) required within 3 months of hire; nationally-recognized risk management certification (i.e. CPHRM from the American Hospital Association) required within 24 months of hire.
  • • Other job-related certifications will be considered on a case-by case basis.
  • • Driver's License and Proof of Insurance may be required if requesting mileage reimbursement.

Required Language Skills:

  • • Ability to comprehend and compose instructions, correspondence and communications in English in both oral and written format.
  • • Ability to effectively present information in one-on-one and small group situations to patients, internal providers and staff and other agency staff working in cooperation with the organization.

Physical Requirements:

  • • Ability to occasionally exert enough force to move objects weighing up to 10 pounds.
  • • Ability to continuously remain in a stationary position.
  • • Ability to occasionally move about inside the work place to access files, office machinery, etc.
  • • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
  • • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • • Ability to discern the nature of sounds at a normal spoken volume.

Chiricahua Community Health Centers, Inc.

Other Required Knowledge, Skills, and Abilities:

  • • Ability to employ statistical / mathematical methods to collect and analyze data and develop solutions.
  • • Ability draw and interpret graphs.
  • • Ability to perform a variety of assignments and make decisions requiring considerable independent judgment.
  • • Displays sound and accurate judgment and ability to make timely decisions.
  • • Knowledge and understanding of all CCHCI policies and procedures.
  • • Knowledge of OSHA requirements in health care.
  • • Knowledge of licensing regulations.
  • • Knowledge of Federally Qualified Health Center (FQHC) and Community Health Center (CHC) requirements.
  • • Computer literacy required with proficiency in use of all Microsoft Office programs.
  • • Knowledge of Electronic Health Records preferred.
  • • Ability to prioritize and plan work activities, use time efficiently and develop realistic action plans.
  • • Ability to employ motivational techniques to train and mentor staff.

Work Environment & Conditions:

  • • Work environment is usually typical of an administrative office setting with no substantial exposure to adverse environmental conditions.
  • • Occasionally, work environment is typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids and hazardous chemicals.
  • • Work requires reliable transportation as position requires occasional travel and extended hours to include early mornings, evenings, holidays and weekends.
  • • Work requires ability to be contacted by cell phone during or outside of regular work hours. Cell Phone stipend will be provided.