Compliance/Risk Manager

Winnebago Comprehensive Healthcare System•Winnebago, NE

23h

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 organization-wide policy review and approval processes, and works with the Patient Safety/Quality Coordinator and department leaders to plan, implement, and evaluate safety activities, reduce risk, and align improvement efforts with the Quality Assurance and Performance Improvement (QAPI) Program. The manager is accountable for program coordination, organizational oversight, and escalation. Department leaders retain accountability for technical assessments, clinical practice, and implementing corrective actions in their areas. Legal matters are coordinated with the CEO and Legal Counsel through established channels. The manager leads the Compliance and Ethics Program, supports ethical conduct and open communication, coordinates compliance education, audits, investigations, remediation, policy governance, and reporting, and maintains appropriate escalation channels for significant concerns. The position leads 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. It coordinates risk assessments, incident reporting and review, patient safety activities, accreditation and survey readiness, required reporting, risk mitigation, and follow-through on corrective actions, while technical controls and implementation remain with responsible departments. The manager maintains a compliance and risk dashboard, analyzes and documents findings and outcomes, communicates significant risks and overdue or ineffective actions, and reports program activities and performance to the Quality Management Committee and Governing Body through established channels. The role integrates findings with QAPI while preserving clear responsibility for compliance, risk management, and quality improvement activities. Other duties may be 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 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 records.
Strong computer skills to extract, compile, enter, analyze, and present data using organizational systems.
Excellent verbal and written communication, staff education, multidisciplinary facilitation, and presentation skills.
Strong organization, confidentiality, and interpersonal judgment, with the 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 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 comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, by signing a pre-employment declaration regarding arrests and convictions for child abuse or violent felonies, and comply with PL 101-630 and PL 101-637 regarding criminal records checks.

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, coordinate its priorities, committee oversight, and reporting, and promote ethical conduct, open communication, and identification and response to fraud, waste, abuse, and other compliance concerns.
Exercise delegated authority to obtain relevant records, convene reviews, and escalate unresolved concerns; maintain direct access to the CEO and Governing Body or designated oversight committee for significant compliance matters.
Coordinate organizational policy governance, including the Policy Committee, multidisciplinary review, approval routing, development, revision, scheduled review, publication, and retirement of policies.
Maintain assigned policy owners, templates, version control, approval records, and access to current approved policies; monitor deadlines, escalate overdue items, and report policy performance.
Coordinate code of conduct development, review, education, and implementation with Human Resources, and support staff understanding and implementation of policy changes and reporting expectations.
Establish internal reviews and audits of clinical and nonclinical activities; analyze findings, evaluate controls, and monitor compliance and program effectiveness.
Lead or coordinate investigations of intended and unintentional misconduct and ensure responses, remediation, ownership, completion dates, and evaluation of sustained effectiveness.
Coordinate an ongoing enterprise risk management process across operational, clinical and patient safety, strategic, financial, human capital, legal and regulatory, technology, and hazard domains.
Coordinate the annual organizational risk assessment 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 risks in processes, staffing systems, credentialing workflows, documentation, communication, chain of command, and adherence to practice; support policies, 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, and 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 patient experience and quality personnel to support 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 reviews, rounds, tracers, and proactive process reviews.
Coordinate patient protection compliance, including patient rights, informed decisions and consent, advance directives, abuse prevention, and restraint and seclusion safeguards.
Coordinate multidisciplinary event reviews and root cause analyses; support prompt protective action, corrective plans, effectiveness measures, sustained improvement evaluation, and escalation of overdue or ineffective actions.
Collaborate on safety culture assessment, staff education, safety alerts, lessons learned, and improvement monitoring.
Coordinate identification, submission, and documentation of applicable mandatory external reports, including abuse concerns and reportable restraint or seclusion deaths.
Advise leadership on risks related to organizational priorities, 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 workforce-related risks, including staffing, competency, credentialing, recruitment and retention, fatigue, workplace injury, workers’ compensation, and workplace violence.
Coordinate CMS certification, applicable Conditions of Participation, accreditation, and continuous survey readiness with the Director of Quality; monitor regulatory changes and coordinate survey responses and plans of correction.
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 technology, privacy, cybersecurity, 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 covering facilities, hazards, equipment, utilities, construction, infection control, and continuity of essential services.
Maintain a compliance and risk dashboard with the Patient Safety/Quality Coordinator; analyze, document, track, and report program findings, risk trends, policy performance, audits, investigations, assessments, event reviews, and corrective action outcomes.
Communicate significant risks, overdue actions, and ineffective controls to the Director of Quality and appropriate oversight committees, and report program performance to the Quality Management Committee and Governing Body.
Perform other duties as assigned.