Director, Risk Management & Performance Improvement

ADDICTION AND MENTAL HEALTH SERVICES • Smithville, TX

3d • Onsite

About The Position

The Director of Risk Management & Performance Improvement oversees the planning, organization, direction, and control of facility risk management activities. The role helps ensure a safe environment for patients, clients, employees, and visitors, and supports compliance with applicable laws, regulations, and accrediting and approval agency standards.

The Director develops and implements risk management and patient-safety systems, investigates and analyzes actual and potential risks, and leads the facility’s Quality Assurance/Process Improvement (QAPI) Program. The position monitors program performance and compliance, supports accreditation and state licensure, and works with clinical and administrative staff to improve care, safety, policies, and procedures. The role also manages department staff and provides consultation and technical support for risk management and performance improvement activities.

Requirements

• Bachelor’s degree in risk management, business, or a related field.
• Five or more years of experience in a risk management position.
• At least one year of supervisory experience.
• Comfort working with the public.
• If recovering, two years of continuous, verifiable sobriety.
• Maintain appropriate professional boundaries and confidentiality.
• Working knowledge of HIPAA (45 CFR) and 42 C.F.R. Part 2, concerning confidentiality of alcohol and drug abuse patient records.
• Ability to maintain composure with periodic exposure to high-risk behaviors that may involve agitation, aggression, or violence, or exposure to critical incidents and possible sentinel events.

Nice To Haves

• Knowledge of federal, state, and local governmental laws and regulations, and applicable accrediting agency standards, rules, and regulations.
• Master’s degree in health care management, nursing, or a related field.

Responsibilities

• Investigate and analyze actual and potential facility risks, assess liability, and evaluate the probability of legal action for potential notification.
• Implement, educate staff about, and encourage use of the facility’s incident reporting system.
• Implement the facility-wide risk management program.
• Develop and implement infrastructure and systems that support patient safety.
• Work with the Clinical Department to ensure employees follow organizational procedures and policies.
• Work with internal auditors, security contractors, and other staff to establish an internal control system.
• Monitor and analyze program performance data to assess effectiveness and identify opportunities for improvement.
• Ensure compliance with administrative requirements.
• Identify high-risk areas that could cause harm to people receiving services, visitors, and employees.
• Maintain a database of full-disclosure activities and oversee review programs, providing technical support as needed.
• Manage staff, including hiring, development, training, performance management, and communication, to support effective department operations.
• Serve as a resource and consultant for risk management, performance improvement, policy and procedure development, and compliance initiatives.
• Collaborate with clinical staff and management to prevent clinical risks throughout the facility.
• Develop working relationships with clinical staff and administrative personnel to facilitate patient care.
• Create and implement policies and procedures that improve patient care and employee safety.
• Ensure application of institutional policies, particularly those concerning patient rights, confidentiality, and full disclosure.
• Develop, implement, coordinate, and facilitate the facility’s Quality Assurance/Process Improvement (QAPI) Program.
• Assess QAPI needs and trends by reviewing practices and gathering, compiling, and evaluating data concerning employees, services, and patient feedback.
• Delegate and support QAPI and risk management activities of Department Directors to achieve desired department-related patient care and safety outcomes.
• Monitor and maintain facility compliance with accreditation requirements.
• Monitor and maintain facility compliance with state licensure requirements.

Benefits

• Medical coverage, including three BCBSAL medical plans with improved rates, co-pays, and prescription benefits.
• Expanded coverage options for domestic partners and access to a wider network of in-network providers.
• Mental health support, including an Employee Assistance Program with digital wellness tools, Cognitive Behavioral Therapy modules, and wellness coaching.
• Voluntary coverages including pet insurance, home and auto insurance, and family legal services.
• Student loan repayment available for nurses and therapists.
• 401(k) plan through Voya.
• Paid time off.
• Voluntary dental, vision, life, accident insurance, and telehealth options for part-time employees working 20 hours or more per week.

What This Job Offers

• Job Type: Full-time
• Career Level: Director