The Manager, Enterprise Risk is responsible for supporting, coordinating, and facilitating the risk management activities for the health system which includes but may not be limited to: identifying, examining and responding to risk-related issues and complaints involving NorthBay Health facilities, employees and medical staff; managing or assisting in risk-related investigations to promote safe patient care, staff safety and identifying potential liability; Complying with risk management related standards of The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and the California State Department of Public Health (CDPH); Collaborating and consulting on complaints/concerns identified through the patient grievance processes and/or NorthBay legal that have risk management implications; monitoring organizational event reporting with primary focus on incidents involving harm or potential liability, and collaborating with Quality and Patient Safety on trending to identify opportunities for improvement; managing and analyzing risk management information (data); proposing, recommending and implementing solutions and resolutions to risk-related issues and events; following up on the implementation and impact of proposed solutions and resolutions; having a general knowledge of organizational insurance programs and resources and collaborating with the legal leaders to manage claims against the organization's insurance program.
The Manager will participate in multidisciplinary teams, standing work groups, councils and committees for the purpose of evaluating and improving organizational risk including patient care. The Manager is responsible for the coordination and investigation of serious adverse events (SAE), including potentially reportable incidents to CDPH and TJC, and in conjunction with the Licensing and Legal departments provides documentation of all related data and facilitates resolution of reported incidents. This individual is responsible for conducting risk management educational and training programs for the organization. Supports the culture of safety survey activities. Leads/participates in formulating risk reduction strategies and is responsible for developing and/or maintaining up-to-date policies and necessary organizational changes related to risk management.
PRIMARY JOB DUTIES- Supervises assigned staff, providing ongoing education and competency development and review, and performs annual evaluations for direct reports.
- Meets organizational standards for The Joint Commission (TJC), Patient Safety (PS), California Department of Public Health (CDPH) and Centers for Medicare and Medicaid (CMS) and acts as a liaison as needed.
- Coordinates the risk management program/plan to meet the needs of the institution.
- Reviews and analyzes all occurrence reports for Risk Management, quality of care, and regulatory concerns.
- Manages High Risk/Sentinel Event investigation process and FMEA groups as assigned.
- Conducts Root Cause Analysis investigations as requested with Quality and Safety, which includes assessing need for focused review by departments, and or clinical chairpersons for peer reviews
- Keeps abreast of all applicable regulatory requirements related to risk management.
- Develops or participates in the development of educational programs to raise staff awareness of risk exposure and the impact on professional liability, including Just Culture and High Reliability Organizations (HRO's).
- Identifies organizational risk through trend analysis of incidents and reports and actively works on proactive risk mitigation.
- In collaboration with patient experience and legal, manages the grievance process including reviewing and responding to complaints.
- Actively participates in committees directed toward promoting and improving quality of care
- Other duties as assigned.
Education:- Bachelor's Degree required, ( nursing or other healthcare related field preferred)
- Master's Degree preferred.
Licensure/Certifications:- CPHQ, CPPS or CPHRM required (or within 24 months of hire).
Experience/Skills: - Proficiency with Microsoft Office software.
- 3-5 years of healthcare Risk Management and/or patient safety experience highly preferred.
- Experience with Vigilanz preferred.
- Minimum of four years hospital-based performance improvement experience required.
- Two years of supervisory or leadership experience highly preferred.
- Medical terminology understanding required.
- Current knowledge of data reporting and regulatory/accreditation requirements for acute and ambulatory care services and federal, state and local healthcare related laws and regulations and the ability to comply with these in healthcare practices and activities.
