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Manager of Patient Safety, Risk & Compliance
Job Code:2018-GANNETT DR-010
Schedule:Full Time 32-40 hrs/wk

Job Responsibilities:

Working under the general supervision of the Chief Human Resources Officer, this position is responsible for planning, organizing, implementing and evaluating the activities of a comprehensive Patient Safety, Risk and Compliance Management program.  This person works closely with the Chief Medical Officer, management team and Department Chiefs on program development for continuous quality improvement, patient safety, satisfaction and risk management.


Personnel Management – 3 direct reports


• Models behaviors that demonstrate service excellence to staff and focus on the patient as the primary customer.
• Works closely with the Chief Medical Officer to foster a culture of continuous quality improvement and patient safety.  Develops systems for objectively monitoring performance.
• Coordinates and co-chairs the activities of the Compliance Committee.
• Collaborates with the committee chairs and assists with incorporating best practices related to patient safety to achieve evidence-based patient outcomes.
• Establishes credibility and presence within the organization. Works collaboratively with physicians and management to establish organizational goals and objectives.  Measures progress.
• Oversees policy inventory to ensure timely review.
• Researches and drafts operational policies and procedures to make practice operations more consistent across the group.  Collaborates across the organization to assist in development and implementation of efficient and effective workflows.
• Handles escalated patient complaints and acts as key patient contact for Administration. Manages crisis situations and unusual problems in a calm, tactful, professional and effective manner.
• Assesses non-employee and employee Incidents and Complaints.  Prepares reports to identify problem prone areas, trends, the facilitation of prevention initiatives, and reporting of results.
• Develops statistical and qualitative reports on risk management trends and patterns and communicates the information effectively to appropriate audiences within the organization.
• Fosters patient engagement and focuses on service recovery to support the strategic plan.
• Supports, embraces and leads change management.
• Provides regular updates to senior leadership on the status and results of projects.


• Stays abreast of federal and state laws and regulations. Recommends and formulates policies, procedures and guidelines.
• Remains knowledgeable of all safety, infection control and disaster policies and procedures.
• Works collaboratively with the Safety Administrator and Facilities team to maintain a safe environment.
• Conducts or organizes patient safety/risk management educational programs.
• Directs the investigation of all potentially compensable events.
• Responds to sentinel events and other serious occurrences and provides expert advice in the management and reporting of such events to administrative and clinical leadership and staff. Initiates root cause analysis as indicated.
• Conducts immediate and appropriate response to any serious occurrence/complaint representing actual or potential patient, visitor, or employee injury.  Monitors and takes action to assure learning, compliance and documentation. Participates in disclosure discussions and monitors the corrective action plan. Maintains a database for trending.

Compliance & Privacy Officer

• Retains and exercises unrestricted access to the CEO and Board of Directors.
• Implements and monitors the Corporate Compliance Plan, including educating all employees of the corporation and promoting use of the compliance hotline.
• Maintains current knowledge of applicable federal and state privacy laws. 
• Remain current on external regulatory requirements including HIPAA compliance.
• Facilitates the development, maintenance, and monitoring of compliance and privacy policies and procedures.
• Establish and oversee practice policies for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the practice’s privacy policies and procedures in coordination and collaboration with other similar functions, and, when necessary, with legal counsel.
• Plans, organizes, and executes compliance and privacy programs.
• Perform periodic risk assessments and ongoing compliance monitoring activities at each site.
• Maintain all business associate contracts and respond appropriately if problems arise.
• Conducts investigations to resolve complaints and report potential violations for adjudication.
• Oversees the performance of regular, periodic audits of the operations and chart reviews of InterMed.
• Cooperates with local, state and federal governmental units and other organizations in identifying needs and providing assistance in enforcement of statutes. Cooperate with the Office of Civil Rights, CMS, other regulatory, accrediting and legal entities and organization officers in any compliance reviews, investigations or surveys.


• Proactively evaluates areas of organizational risk based on internal assessment and external benchmarking.  Implements strategies and policies which promote patient and staff safety.
• Maintains organization’s Risk Management Plan and updates annually.
• Assists in coordinating insurance coverage and risk financing.
• Communicates actual and potential claims as well as legal and regulatory actions to liability carrier(s). Ensures maximum protection from discovery of all materials.  Gives an account of all potential/actual claims to CMO and CEO in a timely fashion. Provides high touch support to providers throughout the claim process.
• Coordinates claims investigation and legal defense processes.  Refers non-malpractice medico-legal issues and cases to counsel and coordinates communication of results.
• Participates in long range planning activities in accordance with operational needs.

Uses Clinical Skills to:

• Analyzes complex medical information and its impact on patient safety and quality.
• Accurately and completely screens medical records.
• Communicates and interacts with all members of the health care team.
• Safeguards all patient information, disclosing it only in accordance with organizational policy and legal requirements.
• Actively seeks new knowledge and expertise in patient safety, regulatory and quality arenas.

Job Qualifications:
• Active RN license with at least five years of acute care experience.
• Bachelor’s degree is required, preferably in nursing or healthcare administration.
• Minimum of 3-5 years quality/risk healthcare experience.
• Current CPHRM, CPHQ, CHC designation, or credential must be attained within 2 years of employment.
• Knowledge of NCQA, HEDIS, The Joint Commission (TJC) National Patient Safety Goals, IHI initiatives, regulations and other patient care related initiatives to improve outcomes.
• Demonstrated commitment to excellence in customer service and clinical care.
• Ability to interpret and apply standards and regulations.
• Proven leadership, communication and training skills; ability to convey understanding of complex issues.
• Ability to multitask, prioritize, organize, and plan work independently.
• Demonstrated ability to plan and carry out projects or change initiatives of significant magnitude; Lean certification preferred.
• Ability to see the big picture, foster an enhanced team environment, think and act strategically, and be proactive.
• Comfortable and skilled working in a collaborative manner with physicians, healthcare providers and management.
• Ability to extract, categorize and analyze data from the electronic medical record and other sources.
• Able to handle sensitive information and maintain confidentiality.
• Strong problem solver; confident with their ability to use independent judgment and discretion.
• Skilled in prioritizing, delegating, communicating and planning.  Excellent interpersonal skills required.
• Consistently demonstrates a self-directed, mature, disciplined and tactful approach to completing work assignments, including competent follow-up on matters requiring additional attention.
• Ability to solve problems that have no clear cut solution and require tact and ingenuity.
• Ability to work under pressure and within deadlines.
• Ability to make decisions using sound judgment.
• Strong computer skills; Microsoft Word, Excel, PowerPoint and electronic medical record.

Other Job Information (if applicable):
40 hours a week, Monday through Friday, 8:00am to 5:00pm with occasional early morning and early evening meetings

InterMed is an Equal Opportunity Employer. If you have any questions about this position, please contact us at

InterMed is an Equal Opportunity Employer.