Senior Director, Clinical Risk Management

Inland Empire Health Plan•Rancho Cucamonga, CA

3h•Hybrid

About The Position

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Chief Quality Officer, the Senior Director of Risk Management provides strategic leadership and oversight for the development and implementation of the health plan’s clinical risk management program and plan. This role is accountable for identifying, assessing, and mitigating risks that could impact organizational performance, regulatory compliance, and member safety. The Senior Director collaborates with executive leadership, operational teams, and regulatory agencies to ensure member safety, adherence to state and federal requirements, accreditation standards, and industry best practices.Key areas of responsibility include: Organizational Leadership & Culture – Driving a culture of member safety and accountability across the organization. Strategy & Program Development – Designing and implementing enterprise-wide risk management frameworks and protocols. Compliance & Regulatory Oversight – Ensuring compliance with all applicable regulations and accreditation standards. Risk Monitoring & Mitigation – Identifying emerging risks and leading proactive intervention strategies. External Relations & Reporting – Building strong stakeholder relationships and providing transparent reporting to leadership and governing bodies. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

A minimum of ten (10) years of progressive experience in clinical risk management within a health plan or healthcare setting
A minimum of three (3) years of proven leadership experience managing enterprise risk programs
Bachelor's degree in nursing and/or related field from an accredited institution
In lieu of the required degree, a minimum of eight (8) years of additional relevant work experience is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issues by the California Board of Registered Nursing required
Must have a valid California Driver’s license
Advanced knowledge of risk management principles, practices and techniques
Knowledge of healthcare/health plan operations, regulations, and compliance requirements
Demonstrated knowledge of healthcare laws and regulations, safety science, and patient safety best practices
Knowledge of healthcare risk financing and health insurance principles
Knowledge of health plan accreditation standards, such as NCQA
Strong knowledge of healthcare laws and regulations, such as HIPAA and HITECH
Strong problem-solving skills to address complex challenges
Strong communication and interpersonal skills, with the ability to interact with all levels of the organization
Mindset of innovation to continuously improve operations and processes while mitigating risks
Ability to assess and mitigate risks for the organization
Ability to effectively communicate risk management concepts to non-technical stakeholders
Ability to build and maintain positive relationships with internal and external stakeholders
Ability to analyze data to identify trends, make recommendations and drive decision-making
Ability to adapt to changing priorities, requirements, business environments and organizational needs

Nice To Haves

A master’s degree in nursing or related field from an accredited institution is preferred
Certified Professional in Patient Safety (CPPS) or other relevant certification preferred
Knowledge of healthcare quality improvement methodologies, such as Lean or Six Sigma

Responsibilities

Foster a culture of member safety by promoting reporting of events, adherence to safety standards, and implementation of best practices to enhance safety across the organization and at provider sites
Provide strategic leadership and direction to the risk management team—including Quality Management and Grievance & Appeals—by overseeing staff development, training, and performance to ensure operational excellence and psychological safety in reporting
Serve as Co-Chair of the Member Safety Subcommittee, along with designated Medical Director, ensuring agendas, discussions, and actions align with the charter and workplan
Coordinate incident management, including event reviews and serve as liaison between both internal and external stakeholders
Partners with Human Resources to ensure application of Just Culture principles when evaluating behaviors related to member safety events
Design and lead an enterprise-wide clinical risk management program, establishing protocols for member complaints, quality reviews, and corrective actions to enhance service delivery
Develop and implement risk management policies and procedures tailored to a health plan environment, ensuring compliance with all applicable regulatory requirements
Draft and publish annual Risk Management and Safety Plan, carry out plan activities, and report measures of success
Lead stakeholder consensus processes to assess and develop detailed action plans for serious risks related to providers or facilities
Ensure compliance of Potential Quality Incidents (PQI), Potentially Preventable Conditions (PPC), Facility Site Reviews (FSR), Medical Record Reviews (MRR), Grievances, and Appeals processes with DHCS, DMHC, CMS, and NCQA requirements, including workflows, communication protocols, monitoring, and reporting
Monitor and evaluate program effectiveness, implementing performance improvement initiatives as needed
Conduct regular risk assessments and audits to identify potential areas for improvement
Lead Skilled Nursing Facility Quality Assurance and Performance Improvement (SNF QAPI) audit programs to maintain regulatory compliance and quality standards
Track and analyze key risk indicators to identify emerging issues and lead proactive mitigation strategies
Lead the efforts to collaborate with Legal, Quality, Member Services, Provider Services, Hospital and Ancillary Relations, and Health Services teams in the development and oversight of member safety initiatives
Develop and maintain relationships with external stakeholders, including other health plans and regulatory agencies, to stay current with industry trends and requirements
Prepare and present risk management reports and updates to executive leadership and Board committees as needed
Hire, train, and manage support staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines
Perform any other duties as required to ensure Health Plan operations and department business needs are successful