Director of Risk and Compliance

Family Health Center of Worcester, Inc.; Worcester (MA); On-site; USD 150,000 - 210,000; Full time

Job summary

Family Health Center of Worcester, Inc. is seeking a Director of Risk & Compliance to provide strategic leadership for Performance Improvement, Regulatory Compliance, Accreditation, and Risk Management programs.

This role ensures HRSA Health Center Program compliance with federal and state regulations and accreditation standards, promoting a culture of continuous quality improvement across the organization.

Qualifications

• Bachelor's in Nursing or Public Health with 5+ years in compliance and quality role
• FQHC experience strongly preferred
• HRSA experience strongly preferred
• Reporting relationship to the Chief Operating Officer

Responsibilities

• Develop and implement the organization's risk and PI strategy.
• Lead organization-wide risk and compliance initiatives.
• Oversee compliance committees and multidisciplinary improvement teams.
• Promote a culture of continuous improvement.
• Coordinate HRSA OSV preparation and HRSA program monitoring.

Skills

Regulatory compliance

Risk management

Quality improvement

Data analytics

Leadership

Healthcare experience

Education

Bachelor's degree in Nursing

Public Health degree

Tools

Policy management software

Audit software

Job description

The Director of Risk & Compliance provides strategic leadership for the organization's Performance Improvement (PI), Regulatory Compliance, Accreditation, and Risk Management programs. This position ensures organizational compliance with HRSA Health Center Program requirements, federal and state regulations, and accreditation standards promoting a culture of continuous quality improvement across the organization.

The Director partners with executive leadership, clinical leadership, operations, and department managers to improve enhance organizational performance, reduce risk, and ensure regulatory readiness. This person will work closely with the director of quality and nursing team as it relates to quality improvement, patient safety, and infection control.

Program Specific Essential Duties and Responsibilities:

• Risk and Compliance Improvement Leadership
• 2. Develop and implement the organization's Risk and Performance Improvement (PI) strategy.
• 3. Lead organization-wide Risk and Compliance initiatives.
• 4. Oversee compliance committees and multidisciplinary improvement teams.
• 5. Promote a culture of continuous improvement throughout the organization.

HRSA Compliance:

Serve as organizational lead for compliance with HRSA Health Center Program requirements including:

• 1. HRSA Health Center Program Compliance Manual
• 2. Operational Site Visits (OSV)
• 4. Program monitoring
• 5. HRSA reporting
• 6. Corrective Action Plans
• 7. Federal grant compliance

Responsibilities include:

• 1. Coordinate HRSA Operational Site Visit preparation.
• 3. Lead corrective action implementation following HRSA reviews.
• 4. Ensure ongoing readiness for HRSA site visits.
• 5. Regulatory Compliance

Ensure compliance with:

• 1. CMS Conditions of Participation
• 2. HIPAA
• 3. DEA regulations
• 4. CDC recommendations
• 5. Massachusetts Department of Public Health regulations
• 6. Federal and state healthcare regulations
• 7. Accreditation

Lead accreditation activities including:

• 1. Readiness assessments
• 3. Policy review
• 4. Staff education
• 5. Survey coordination
• 6. Corrective action planning
• 7. Continuous accreditation readiness
• 8. Works closely with Clinical Quality & Patient Safety teams

Oversee:

• 1. Patient safety reporting
• 3. Failure Mode and Effects Analysis (FMEA)
• 5. Near miss reporting

Implement systems to improve:

• 2. Access to care
• 3. Care coordination

Provide oversight for:

• 2. Clinical risk
• 4. Adverse event investigations
• 6. Medical record audits
• 8. Corrective action tracking

Partner with legal counsel and insurance carriers regarding risk mitigation activities.

Data Analytics & Performance Reporting

Develop dashboards that monitor:

• 2. Access metrics
• 3. Financial quality indicators
• 4. Regulatory compliance indicators

Use data analytics to identify trends and recommend improvement strategies.

Policy & Procedure Management

• 1. Develop and maintain organizational policies.
• 2. Ensure policies reflect current federal and state regulations.
• 3. Coordinate annual policy review.
• 4. Monitor implementation and compliance.
• 5. Staff Education
• 6. Report to Board of Directors Policy and Procedure Committee (ss add)

Develop compliance education programs covering:

• 1. Regulatory updates
• 4. Infection prevention
• 5. HRSA requirements
• 6. Quality Improvement methodology
• 7. HIPAA

Qualifications and Education Requirements:

One of the following combinations of education and employment experience must be met in order to be considered for the position:

Education And Experience

Bachelors in Nursing or Public Health and5 + years working in compliance and quality role

FQHC experience strongly preferred

HRSA experience strongly preferred

Reporting Relationship: Chief Operating Officer