Our behavioral health hospital is now recruiting a Compliance and Risk Director to be responsible for planning, directing, and organizing the Compliance and Risk Management functions of our hospital. In addition to these responsibilities, the CR Department is responsible for assisting administration with the training and implementation of Joint Commission requirements and activities and will assist in organization efforts toward maintaining Joint Commission accreditation, licensure as a hospital with the State of Nevada, and specific payor requirement audits.

Education / Licensure:

• Bachelor’s Degree in Nursing required and a current Nevada R.N. license. Master’s degree preferred. Certified Professional in Healthcare Quality (CPHQ) preferred.
• Experience and/or level of competency: At least 5 -7 years of relevant behavioral hospital experience in quality, compliance and risk management, healthcare improvement, patient safety, regulatory and accreditation.
• Health Care Improvement Certification(s) a plus

Essential Job Functions and Responsibilities:

Conducts monthly Quality and Performance Improvement Council meetings.

Ensures PI teams meet as assigned. Provides guidance and insight for those teams and ensures reports are collected in a timely fashion.

Participates in the identification and development of goals and objectives for organization wide staff development programs and strategic planning efforts.

Develops and coordinates implementation of goals and objectives for organization wide performance improvement programs.

Develops and coordinates implementation of goals and objectives for organization wide risk management programs.

Offers in-service training to all employees, on an as-needed basis, regarding compliance, performance improvement and risk management issues.

Prepares monthly analysis reports of aggregate data and submits to appropriate committees for review.

Assists the CEO with the preparation of Governing Board and Medical Staff meetings and reports.

Collects and analyzes data results of chart audits and makes recommendations for improvement measures.

Attends education sessions to continually update knowledge base related to the position.

In conjunction with the Human Resource department, ensures policy and procedure manuals for the facility are updated in a timely fashion and continue to follow an organized format. Ensures any changes are communicated appropriately to all pertinent staff.

Supports hospital’s internal and external customer service standards.

Communicates pertinent information to managers/ directors / in a timely manner.

Provides in-service training specific to PI and Risk-related issues based on the identification of facility needs and requests and collaborates with Human Resources in the orientation process of the new employees.

Provides Patient Advocate services to consumers and their families.

Assists with data entry and the timely reporting of required data to The Joint Commission and the Centers for Medicare and Medicaid Services.

Manages and resolves all complaints and grievances. Responds to compliments and suggestions as part of the overall performance improvement process.

Manages and provides oversight to the hospital’s incident reporting system, to include adverse and sentinel events. Engages in appropriate and required reporting of serious incidents and events to governmental and accrediting bodies, when needed.

Provides management and oversight of the customer experience by providing feedback to staff and leaders from the Press Ganey® Patient Satisfaction Survey results.

Participates in the monthly Hospital Safety Committee.

Performs other duties as assigned by the CEO. Maintains a collaborative relationship with departmental directors, managers and supervisors, the Medical Director and physician team, all\other staff members of the facility, and with outside referral services.

Our hospital provides access and services to all persons meeting admission and continuing stay criteria without regards to race, color, religion, sex, sexual orientation, age, marital status, national origin, military status, veteran status, medical status, handicap or mental/physical disability. Our patient population reflects the fullest diversity of the community in which we serve. All staff are to conduct themselves with respect and consideration for others, and to appropriately intervene in situations below this standard.

Demands/Work Environment:

Environment: Located in an indoor climate-controlled environment with constant exposure to patients with a psychiatric diagnosis along with medical complications. Patient acuity will at times increase environmental stressors and sound volume.

Sight: Vision abilities required include close vision, distance vision, color vision, peripheral vision, depth perception and ability. to adjust focus.

Hearing: Must be able to hear and respond to others in person, by telephone, alarms and to medical equipment/devices.

OSHA Category 1: Task occasionally may involve exposure to blood, body fluids, tissue and other potentially infectious materials. The use of universal precautions, persona/ protective equipment, regular hand washing, and following manufacturing guidelines can greatly reduce exposure risk.

Physical: This position requires regular sitting, stooping, standing, walking and lifting/reaching/carrying materials up to 35 lbs. Psychiatric emergencies require the use of safe physical techniques to lift and/or move patients in excess of 1001bs. Some patient care settings may have patients requiring assistance in repositioning and transferring from bed to chair.

Job Type: Full-time

Pay: $90,000.00 - $110,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Salt Lake City, UT: Reliably commute or planning to relocate before starting work (Required)

Education:

• Master's (Preferred)

Experience:

• Risk management: 5 years (Preferred)
• Behavioral health: 5 years (Preferred)
• Compliance management: 5 years (Preferred)

License/Certification:

• RN License (Preferred)

Work Location: One location

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