STATUS: Exempt, full or part-time hours available; hybrid schedule (in-office/ work from home) available

IMMEDIATE/ CLINICAL SUPERVISOR: Chief Operating Officer

SUPERVISORY RESPONSIBILITIES: None

WHO YOU ARE:

YOUR ROLE & IMPACT

As part of the dynamic team of Charles River Community Health (CRCH), a healthcare practice providing comprehensive and compassionate care to underserved communities, the Associate Director of Patient Safety and Risk Compliance is responsible for planning, coordinating, monitoring, assessing and implementing activities for risk mitigation and increased compliance across the organization. This includes responsibility for ensuring all requirements are met for Health Resources and Services Administration (HRSA), MA Department of Public Health (DPH), Community Care Cooperative (C3), and other applicable federal, state, and local regulatory and/or accrediting agencies. The Associate Director of Patient Safety, Risk and Compliance researches and interprets assigned requirements and standards, assesses impact on CRCH and recommends and implements solutions to minimize risk and maximize compliance. The Associate Director of Patient Safety, Risk and Compliance also leads the organization’s risk management and compliance training program and maintains related policies and documentation to create an environment of continuous compliance.

YOUR RESPONSIBILITIES

• Notifies management, internal and external stakeholders of any incidents of high-risk significance and initiates intensive investigations and root cause analysis as defined by organizational policies and procedures, and makes recommendations to solve individual risk incidents as well as system-wide changes to reduce risk going forward.

• As the risk and compliance expert resource for CRCH, provides education to CRCH leaders, staff and clinicians across all departments on the topics of risk management, and compliance utilizing CRCH MedTrainer (an online educational tool) and other resources. Serves as a health center resource on risk and compliance, as well as emergency management, content in orks with the Senior Leadership Team and managers to establish an annual risk and compliance training plan at the organizational and department level, and ensures completion of all training. On-site Compliance Rounding required along with regular on-site shadowing of clinical services in all areas to stay in compliance with evidence based guideline

• Leads the organization in developing, updating and maintaining patient safety, risk and compliance, emergency management, other clinical and operations policies, procedures and objectives along with department subject matters, as needed. Ensures the most recent versions

• of policies are uploaded into the MedTrainer system in order to have quick access for accreditation, site visits and for employee reference.

• Leads and coordinates the validation of actual clinical and operations performance versus policy and procedures outlined. Assists departments to ensure the two are in alignment.

• Follows through on patient complaints and grievances to ensure they are resolved, as well as tracking them in the MedTrainer system. Take the lead in developing patient complaint/grievance dashboard, analyze result and reports with meaningful trends and insight to leadership and C3 (for MassHealth enrolled patients).

• Follows through on incidents involving patients, employees, or anyone else on-site at a CRCH facility, tracks in MedTrainer system and analyzes and reports with meaningful trends and insight to leadership. Works with facilities and HR to address any needed improvements to mitigate future risk.

• Responsible for staying current on Risk & Compliance regulations and making annual recommendations for updates to core training offerings for CRCH staff to take. Takes the lead in establishing and carrying out CRCH Annual Risk Management Training.

• Develops and maintains Risk and Compliance Dashboard/Data and provide regular updates and recommendations to Senior Leadership Team in order to mitigate risk.

• Responsible for the ongoing CRCH wide accreditation status, directs the self-assessment, site visit, and malpractice renewal process [F.T.C.A. application] as required by HRSA. On annual basis, assesses, coordinates, and submits required HRSA items. Monitors action plans throughout the year for compliance.

• Takes the lead for the ongoing CRCH wide licensure and certification status, and directs the self-assessment, site visit and clinic licensure’ renewal process as required by the state Department of Public Health. Ensures compliance and maintenance of related certificates including CLIA for on-site laboratory services.

• Accountable for the ongoing CRCH Patient Centered Medical Home certification and is responsible for renewal. Works with clinical and operational leaders to ensure compliance and maintenance of related documentation.

• Works in concert with Chief Operating Officer, Chief Clinical Officer, Nursing, Clinical and Operational management when necessary, in gathering and documenting information pertaining to all potential liability claims and high risk areas.

• Assists senior management/ leadership and directors in the coordination of on-site investigations by various external reviewers (i.e. DPH, CMS, HRSA).

• Assist senior management and directors in the implementation and ongoing measurement of various CRCH initiatives relating to patient safety, patient satisfaction, risk and compliance, and safety standards.

• Responsible for preparing reports for various committees and regulatory applications, as assigned by senior leadership.

• Assists the Chief Operating Officer in the development and maintenance of CRCH Emergency Plan, Policies and Procedures, Communication Plan, and Emergency Preparedness Training and drill/ test development and implementation.

• Stays up-to-date on regulatory and external policy changes impacting CRCH and recommends policy and procedure changes to leadership for implementation

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS

• Bachelor’s degree in health care field. Demonstrated knowledge of patient safety, risk management, and health care compliance. Clinical background preferred.

• 3 or more years in similar role, with increasing responsibilities preferred.

• Seeking a highly adaptable and detail-oriented leader who can effectively collaborate with all levels of staff and management.

• Excellent project management and attention to detail, with ability to manage and complete multiple projects and high quality work on-time.

• Ability to self-initiate creative problem solving to resolve unexpected challenges or barriers.

• Proficient in Microsoft Word, Excel, Power Point and Outlook, including maintaining database spreadsheets and report writing and presentations.

• Proficient in Electronic Health Record and Practice Management systems.

• Proficient in researching, reading, and implementing regulatory guidance to ensure continuous compliance.

• Willingness to become a Certified Professional in Health Care Risk Management.

• Spanish language skills preferred for patient-facing work.

• Experience working with diverse populations desirable and preferred.

• Ability to work with multiple levels in the organization including staff, managers, directors, senior leaders, medical executive committee and board of directors.

• A high degree of ethics and confidentiality is essential for dealing with highly sensitive patient care/ safety and risk compliance matters.

WHO WE ARE & WHAT WE DO

Charles River Community Health’s mission is to improve the health and well-being of the communities of Allston, Brighton, Waltham and surrounding areas by providing quality, compassionate, coordinated care that is patient-centered, family friendly, and community focused.

CRCH is a comprehensive practice providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities. We serve over 15,000 patients annually, and 80% of those served are well below the poverty line while over 60% speak in a language other than English.

We are committed to providing patients with timely access to the right care, at the right place and at the right time, collaborating with other organizations to connect patients with a comprehensive range of services and provide continuity of care, and creating new community partnerships to meet the changing needs of patients and the community.

We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial and other barriers to care, and eliminating health care disparities for our patients. We also advocate for the needs of our patients, the community, and public health causes.

OUR PROMISE

If you are passionate about providing service excellence in a mission-driven, team-oriented, and progressive organization, you will find your career as the Associate Director of Patient Safety, Risk and Compliance rewarding and impactful! You will also find a partner in your career path goals and trajectory!

OUR BENEFITS & PERKS

Medical & Dental Insurance

Short & Long-term Disability Insurance

Generous Paid Time Off

Flexible Spending Account

Employee Assistance Program

Tickets at Work

Health Reimbursement Arrangement

Travel Reimbursement

Professional Development Opportunities

Solid track record of developing and promoting employees internally!

Charles River Community Health is strongly committed to diversity and a workplace environment that respects, appreciates and values employee differences and similarities. By providing and supporting a work culture that fosters and builds upon diversity and its strengths, CRCH will better serve our local communities and continue to provide quality patient care and services. CRCH is an employment at-will organization and an equal opportunity employer committed to maintaining a work and learning environment free from discrimination on the basis of sex, race, color, religion, national origin, pregnancy, gender identity, sexual orientation, marital/civil union status, ancestry, place of birth, age, citizenship status, veteran status, political affiliation, genetic information or disability, as defined and required by state and federal laws. Additionally, CRCH prohibits retaliation against an applicant or employee because he or she has engaged in protected activity under the statutes prohibiting discrimination in the workplace.