Compliance/Risk Manager

Winnebago Comprehensive Healthcare System•Winnebago, NE

18h

About The Position

The Compliance/Risk Manager provides organizational leadership, direction, coordination, and oversight of regulatory compliance, the Compliance and Ethics Program, enterprise risk management, accreditation readiness, and policy governance. The role coordinates the Policy Committee and policy review and approval processes, and collaborates with the Patient Safety/Quality Coordinator and department leaders to plan, implement, and evaluate safety activities, reduce risk, and align improvement with the Quality Assurance and Performance Improvement (QAPI) Program. The manager leads compliance across seven core elements and coordinates risk management across eight domains: operational, clinical and patient safety, strategic, financial, human capital, legal and regulatory, technology, and hazard. The role coordinates program activity, organizational oversight, and escalation; department leaders retain responsibility for technical assessments, clinical practice, and corrective-action implementation in their areas. Legal matters are coordinated with the CEO and Legal Counsel through established channels. Formal Compliance Officer authority is established by organizational appointment. The position coordinates audits, investigations, incident and grievance follow-up, root cause analyses, regulatory and accreditation readiness, policy governance, risk assessments, and corrective-action monitoring. It maintains program reporting and dashboards, escalates significant risks and overdue or ineffective actions, and reports program performance through the Quality Management Committee and Governing Body. The manager also performs other duties as assigned.

Requirements

Bachelor’s degree required.
Minimum of two years of experience in risk management and compliance.
Broad functional knowledge of healthcare laws, regulations, and accreditation requirements, including applicable CMS Conditions of Participation, EMTALA, the Privacy Act, HIPAA, and Joint Commission standards.
Thorough working knowledge of CMS requirements, QAPI, and case management.
Working knowledge of patient safety, infection prevention and control, emergency preparedness, and Environment of Care requirements.
Ability to lead compliance program elements, coordinate assessment across the eight enterprise risk domains, oversee organizational policy management and Policy Committee processes, and collaborate with the Patient Safety/Quality Coordinator and department leaders while maintaining clear accountability.
Knowledge of event investigation, root cause analysis, proactive risk evaluation, corrective-action development, and evaluation of sustained improvement.
Ability to identify and prioritize problems, establish evaluation criteria, select and implement data collection methods, interpret statistical findings, recommend and implement improvements, and maintain accurate documentation and records.
Strong computer skills to extract, compile, enter, analyze, and present data using organizational systems, including an Electronic Health Record, data repository, Excel, Word, PowerPoint, electronic incident reporting, and policy management systems.
Excellent verbal and written communication, staff education, multidisciplinary facilitation, and presentation skills for large and small audiences.
Strong organization, confidentiality, interpersonal judgment, and ability to manage competing priorities with minimal supervision.
Ability to lift up to 10 pounds; walk, stand, and sit for extended periods; and use hands to operate a computer keyboard, telephone, and other office equipment.
Ability to read, write, calculate, reason, analyze, and solve problems; demonstrate strong interpersonal and social interaction skills; and work with minimal to no supervision.
Ability to read, write, and speak English fluently and communicate professionally and effectively.
Applicants must sign a pre-employment declaration regarding arrests and convictions of child abuse or violent felonies and comply with the stated criminal-record-check requirements under 45 CFR 1301 and PL 101-630 and PL 101-637.

Nice To Haves

Master’s degree.
Health-related degree.
Hospital risk management or compliance experience.
Certified Professional in Health Care Risk Management (CPHRM) certification.

Responsibilities

Lead the Compliance and Ethics Program, promote ethical conduct and open communication, and identify and respond to fraud, waste, abuse, and other compliance concerns.
Coordinate compliance program leadership, committee oversight, priorities, and reporting with the Director of Quality; use delegated authority to obtain records, convene reviews, and escalate unresolved concerns.
Maintain direct access to the CEO and Governing Body or designated oversight committee for significant compliance matters, including leadership concerns or conflicts of interest.
Coordinate the Policy Committee and organizational policy development, multidisciplinary review, approval, publication, scheduled review, revision, and retirement; maintain policy owners, templates, version control, approval records, and access to current policies.
Coordinate code of conduct development, review, education, and implementation with Human Resources; monitor policy deadlines, escalate overdue items, report policy performance, and support communication and implementation.
Coordinate compliance education and support staff understanding of policies, reporting expectations, and lessons learned.
Establish internal reviews and audits of clinical and nonclinical activities; analyze findings, evaluate controls, and monitor compliance and program effectiveness.
Promote accessible reporting of concerns and communicate compliance goals, findings, and achievements through appropriate channels.
Lead or coordinate misconduct investigations and ensure appropriate response, remediation, assigned owners, completion dates, and evaluation of sustained effectiveness.
Support fair and consistent application of compliance expectations with Human Resources, leadership, and Legal Counsel; escalate significant concerns and overdue or ineffective corrective actions.
Lead an ongoing process to identify, assess, prioritize, mitigate, and monitor risks across operational, clinical and patient safety, strategic, financial, human capital, legal and regulatory, technology, and hazard domains.
Coordinate annual organizational risk assessments and event- or change-triggered reviews; maintain a centralized inventory of requirements, risk owners, schedules, findings, mitigation plans, and status.
Partner with department leaders to assess process, staffing, credentialing, documentation, communication, chain-of-command, and practice risks, and support policy development, change management, and controls.
Coordinate monitoring of applicable CMS operating requirements, including bed limits, annual average acute inpatient length of stay, and continuous emergency service availability, with Nursing, Case Management, and administration; escalate exceptions.
Coordinate electronic incident reporting with the Patient Safety/Quality Coordinator, including triage, assignment, investigation, trend analysis, follow-up, and timely closure.
Collaborate with the Patient Experience Specialist or Patient Advocate and the Patient Safety/Quality Coordinator to ensure timely complaint and grievance escalation and resolution, and follow-up on related safety concerns.
Collaborate with the Patient Safety/Quality Coordinator and clinical leaders on patient safety activities aligned with QAPI and evidence-based care, including quality-of-care and documentation reviews, safety rounds, tracers, and proactive process reviews.
Coordinate review and improvement activities addressing medication safety, falls, patient identification, communication, care transitions, infection prevention, hospital-acquired conditions, suicide, self-harm, and applicable ligature or environmental risks.
Coordinate patient protection compliance with responsible leaders, including patient rights, informed decisions and consent, advance directives, abuse prevention, and restraint and seclusion safeguards.
Coordinate multidisciplinary event reviews and root cause analyses with the Patient Safety/Quality Coordinator; support data analysis, chart review, and staff interviews.
Work with responsible leaders to ensure prompt escalation and protective action for serious events and near misses; develop corrective plans with owners, deadlines, and effectiveness measures and escalate overdue or ineffective actions.
Collaborate on safety culture assessment, staff education, safety alerts, lessons learned, and improvement monitoring.
Coordinate identification, timely submission, and documentation of applicable mandatory external reports, including abuse concerns and reportable restraint or seclusion deaths, with designated leaders and Legal Counsel.
Advise leadership on risks related to organizational priorities, new or changing services, partnerships, affiliations, contracts, conflicts of interest, reputation, and changing community or regulatory expectations.
Collaborate with Finance, revenue cycle leaders, executive leadership, and Legal Counsel to assess claims, malpractice, litigation, insurance, billing and collection, fraud, waste, abuse, and business interruption exposures.
Partner with Human Resources, Employee Health, Medical Staff leadership, and department leaders to assess staffing, competency, credentialing and privileging, recruitment and retention, turnover, absenteeism, fatigue, workplace injury, workers’ compensation, and workplace violence risks.
Coordinate CMS certification, applicable Conditions of Participation, accreditation, and continuous survey readiness with the Director of Quality; monitor regulatory changes, coordinate survey responses and plans of correction, and verify sustained compliance.
Oversee compliance review and tracking of required agreements and contracted services, confirm accountable owners, and support integration of contracted-service performance into QAPI.
Coordinate tort claims, disclosures, administrative investigations, boards, issue briefs, state licensure board reporting, and other legal, liability, and contractual matters with authorized leaders and Legal Counsel.
Prepare draft responses to Tribal, State, and Federal Courts and outside agencies for CEO review in coordination with Legal Counsel.
Partner with Information Technology, Clinical Informatics, privacy and security personnel, and equipment owners to assess electronic health record, privacy, cybersecurity, clinical technology, medical device, data integrity, availability, and downtime risks.
Coordinate privacy concerns and breach evaluation with designated Privacy and Security Officers; formal officer responsibilities remain with appointed individuals unless separately assigned.
Partner with Environment of Care, Facilities, Safety, Security, Infection Control, and Emergency Preparedness to coordinate risk assessments for safety, security, hazardous materials and waste, fire and life safety, equipment, utilities, construction and renovation, construction infection control, natural and property hazards, facility and community hazards, and continuity of essential services.
Maintain a compliance and risk dashboard coordinated with the Patient Safety/Quality Coordinator and quality reporting to evaluate program effectiveness, risk trends, policy performance, findings, assessment completion, event review, and corrective-action outcomes.
Ensure findings, program activities, and improvement results are analyzed, documented, tracked, and reported; communicate significant risks, overdue actions, and ineffective controls to the Director of Quality and appropriate oversight committees.
Report Compliance and Risk Management Program activities and performance to the Quality Management Committee and Governing Body through established channels, integrating findings with QAPI while maintaining clear accountability for compliance, risk management, and quality improvement.
Perform other duties as assigned.