Director, Post Acute Care Risk Management, Quality and Compliance

Job Summary:

Job Summary

 

Serves as the Post-Acute Care (PAC) division leader for risk management, quality, resident safety, and regulatory compliance across Covenant's skilled nursing facilities, assisted living and independent living communities, and memory care programs. Leads the PAC risk management program, including incident reporting and investigation, state and federal event reporting, claims and litigation support, and risk reduction strategies. Serves as the PAC expert in accreditation, compliance, and regulatory topics and provides guidance and leadership in quality and safety initiatives and compliance strategies. Facilitates a continuous state of readiness surrounding licensure, accreditation, and certification programs to ensure compliance with state and federal rules and regulations for Covenant facilities. Supports the coordination of regulatory compliance activities, including assessment of standards compliance, survey preparation, mock surveys, and survey follow-up. Provides consultation to Covenant managed and affiliated organizations as required.

 

 

Job Responsibilities:

Risk Management

·       Leads the PAC risk management program; identifies, assesses, and mitigates clinical, operational, and liability risks across all PAC facilities and communities. Participates in Covenant system Legal and Risk management meetings, including weekly reporting to leadership and active participation in status reporting and claims management meetings.

·       Oversees the incident and occurrence reporting system. Reviews reports promptly, ensures complete documentation and follow-up, and trends events by facility and type, including falls, pressure injuries, elopements, medication events, resident-to-resident altercations, and injuries of unknown origin.

·       Ensures allegations of abuse, neglect, exploitation, and misappropriation, injuries of unknown origin, and other reportable events are reported to state and federal agencies within required timeframes, and that facility investigations and follow-up reports are complete, accurate, and timely.

·       Leads or facilitates root cause analyses and investigations of serious and sentinel events; works with facility leadership to develop, implement, and monitor corrective action plans.

·       Serves as the division liaison to Covenant Legal, insurance carriers, and defense counsel on potential and actual claims. Ensures early notification of claims exposure, maintains claims and litigation files, and coordinates responses to record requests, subpoenas, and depositions.

·       Reviews resident and family grievances and complaints with potential risk exposure; guides facility leaders on investigation, communication, and disclosure.

·       Provides loss history, risk data, and facility risk assessments to support insurance renewals and underwriting.

·       Reviews and recommends updates to policies and procedures with risk implications, including abuse prevention, falls, elopement, restraints, and incident reporting.

·       Educates facility leaders and staff on incident reporting, abuse prevention, event investigation, documentation standards, and risk reduction.

·       Protects the confidentiality and privileged status of risk management, peer review, and quality improvement work product in accordance with applicable law and Covenant policy.

Regulatory Compliance and Accreditation

·       Researches and maintains compliance and accreditation requirement expertise, including standards, Requirements and Conditions of Participation, and state and federal regulations.

·       Scans the regulatory environment to ensure that Covenant is operating with the most current and relevant information. Distills the applicable information and provides guidance and interpretation to internal and external customers on current regulatory requirements, readiness standards updates, and other accreditation readiness education strategies.

·       Facilitates compliance with federal, state, and local regulatory requirements as well as additional certifications and awards, and assists Covenant organizations in survey preparation.

·       Reviews accreditation, licensing, and certification survey reports in a timely manner and provides assistance with corrective action plan development. Coordinates with Covenant Legal as required.

·       Represents Covenant Health Systems as appropriate in designated public, regulatory, and accreditation programs.

Quality and Patient Safety

·       Promotes quality, safety, risk reduction, and clinical performance improvement throughout the organization.

·       Coordinates quality, safety, and risk metric reporting to Covenant Health Systems; maintains an integrated PAC risk and quality dashboard for Quality and Safety committees, PAC division leadership, Covenant Corporate Leadership Team, and the Board as required.

·       Provides management reports and updates on emerging compliance, regulatory, and risk issues.

·       Supports facility Quality Assurance and Performance Improvement (QAPI) programs and integrates incident, grievance, and claims data into QAPI priorities and performance improvement projects.

·       Collaborates with PAC CNO and COV CMO in quality improvement and patient safety initiatives, including survey development and administration, tool development, data analysis, dashboards, and reporting.

·       Serves as a resource to Covenant's Quality Oversight Committee and Board Quality and Safety Committee to ensure the best evidence-based and cost-effective practices system-wide.

·       Collaborates with internal partners to provide support for initiatives such as value-based purchasing, clinically related group purchasing arrangements, and outsourced clinical and professional services.

·       Serves as a resource for and support for EHR standardization and documentation, including incident reporting and risk-related clinical documentation.

·       Provides support to facilities interested in developing specialized programs or services and/or creating specialized care capacity.

General

·       Regularly travels to Covenant's post-acute care facilities and communities.

·       Participates in and provides support for additional Covenant committees, as requested.

·       Abides by the Standards of Conduct, which are the basis for the Organizational Integrity Program.

·       Supports and promotes the mission and values of Covenant Health Systems and the Catholic Health Ministry.

 

 

 

Job Requirements:

·       Bachelor of Science in Nursing required.

·       Master's degree in a health discipline or business preferred.

·       Current and unrestricted Registered Nurse (RN) license required.

·       Seven to ten years of experience in health care management, including experience in both risk management and quality/patient safety, as well as regulatory compliance. Post-acute or long-term care experience is strongly preferred.

·       Working knowledge of CMS Requirements of Participation for long-term care facilities, state assisted living regulations, the survey process, and federal and state abuse and incident reporting requirements.

·       Demonstrated experience conducting event investigations and root cause analyses, and working with legal counsel and insurers on claims.

·       Demonstrated understanding of regulatory affairs and quality improvement functions and principles.

·       Knowledge and experience with performance improvement tools and techniques, including Lean.

·       Certified Professional in Health Care Risk Management (CPHRM) and/or Certified Professional in Healthcare Quality (CPHQ) preferred.

·       Proficiency in the Microsoft Office suite (Word, Excel, PowerPoint, and Outlook) and electronic incident reporting systems.

·       Experience with and proficiency in using EHR’s, preferrable within post-acute or long-term care institutions.

·       Demonstrated success working in a team environment, with strong communication skills and proven ability to build effective working relationships.

·       Ability to set priorities, meet deadlines, and work independently without close supervision.

Covenant Health Mission Statement

We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.

Our Core Values:

•Compassion

We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering.

•Integrity

We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources.

•Collaboration

We work in partnership, dialogue and shared purpose to create healthy communities.

•Excellence

We deliver all services with the highest level of quality, while seeking creative innovation.

Applicants, employees and former employees are protected from employment discrimination based on race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability, and genetic information (including family medical history).

Comp Range:

$107,875.68 - $150,018.13

Rate of pay displayed reflects the beginning of the pay scale.  At the time of an offer, determination of your offer will reflect your skills and experience as it relates to the position.