*Raleigh General Hospital* Who We Are: *People are our passion and purpose.*Come work where you are appreciated for who you are not just what you can do. Raleigh General Hospital is a 300 bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services. Where We Are: Beckley is an ideal place to live and boasts many scenic, cultural, and recreational opportunities. From restaurants and breweries to art galleries and unique attractions, Beckley is an outdoor playground with something for all tastes. Why Choose Us: · Health (Medical, Dental, Vision) and 401K Benefits for full-time employees · Competitive Paid Time Off / Extended Illness Bank package for full-time employees · Employee Assistance Program – mental, physical, and financial wellness assistance · Educational assistance and tuition assistance for qualified applicants · Professional development opportunities and CE assistance · And much more… Position Summary: Directs, controls and evaluates the activities, functions, and management of personnel within the Quality/Performance Improvement, Risk Management, and Medical Staff Office departments as well as effectively managing and meeting fiscal goals defined for these departments. Responsible for facility-wide regulatory compliance. Serves as the Patient Safety Officer and Ethics and Compliance Officer. Achieves shared operational management among leadership, medical staff, and clinical employees to continually improve patient care outcomes. Implements the vision, goals, and strategies of the Senior Leadership team as a dynamic leader with excellent communication skills and the ability to motivate and continually advance clinical practice and patient experiences. Collaborates with physicians, clinical managers and other members of the health care team to coordinate activities between the hospital and physicians, promote optimum patient care/service, identify and resolve barriers, and promote growth in patient volume. Oversight and continued implementation of the Ethics & Compliance Program and the facility's compliance with requirements of federal health care programs. Conducts independent investigations on ethics and compliance issues and ensures all E&C standards and policies and procedures are communicated to each LifePoint colleague, agent and independent contractor according to the requirements of each position and then adhered to accordingly. Fosters and environment where colleagues know they can raise concerns or report suspected code violations. QualityFacility oversight of performance improvement programFacility oversight of regulatory and accreditation programFacility oversight of risk management programFacility oversight of patient safety programLeads the Quality/Risk/Medical Staff Office Department within defined financial priorities Risk ManagementConducts clinical risk assessments and analysis of complex organizational systems within the facility and facilitates development of corrective action plan.Formulates analysis plan for data managementOversees investigations of incidents that could lead to professional/general liability claims.Develops policies and procedures related to Risk Management.Disseminates information and research related to changes in regulatory requirements and clinical research pertinent to potential liability exposures and risk issuesConsults with LifePoint PSOrg, LLC on all occasions when the Hospital receives a request for dissemination of PSOrg related information, as well as other PSOrg compliance related issues.Develops, implements and presents educational program for Employees, the Medical Staff and the BoardObtains a minimum of 15 hours of continuing education in Risk Management on an annual basis.Participates in review and development of committee structure and membership for facility.Devises quality report cards for Physicians and Advanced Practice Practitioners Regulatory ComplianceOversees hospital-wide Quality and Performance Improvement program.Plans, organizes and implements performance improvement activitiesPlans and organizes Six Sigma team activitiesProvides for ongoing education on PI and Six Sigma processesCoordinates CMS/TJC Core Measures activitiesPlans, organizes, and implements Regulatory and Accreditation programServes as contact person and liaison between the hospital and accreditation/regulatory agencies, both on a Federal and State level. Ethics & ComplianceServe as Chair for the Facility Ethics & Compliance Committee.Conducting Investigations, encouraging Reporting without fear of retaliation and advising colleagues on E&C matters.Coordinating and supporting Corporate monitoring and auditing procedures and establishing and maintaining formalized monitoring programs.Identifying trends related to ethics and compliance within the facility and participate in communication and interfaces with Service Center ECOs, Corporate Departments and other ECOs.Serving as liaison to the facility's Senior Administration and Department Directors. Reports to: Chief Executive Officer Minimum EducationBachelor’s degree - RequiredMaster's Degree - Preferred Required SkillsRequires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Certifications:□ Basic Life Support (BLS) Required Licenses[West Virginia, United States] Other CPHRM and CPPS required or will obtain within first two years of employment. Maintains current license in profession. Minimum Work ExperienceMinimum 5 years health care experience preferred (clinical experience preferred). Minimum 2 years experience in clinical risk management preferred. Supervisor and/or management experience preferred. EEOC Statement: Raleigh General Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law. **Job:** **Quality* **Organization:** **Raleigh General Hospital* **Title:** *Director of Quality and Risk* **Location:** *West Virginia-Beckley* **Requisition ID:** *7418-11436*