AVP of Risk and Regulatory Compliance

This position maintains company-wide responsibility for multiple areas including Risk Management, as well as close collaboration with Corporate Chief Compliance Officer on matters addressing facility based regulatory and licensure compliance. The AVP of Risk/Regulatory provides leadership and expertise to ensure the delivery of safe, high quality patient care services. ESSENTIAL DUTIES AND RESPONSIBILITIES: To perform this job successfully, a staff person must be able to perform each of these essential duties satisfactorily. The requirements listed below reflects the overall knowledge, skill, and/ or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties listed below: Sits on the Corporate Compliance Committee. Serves as a resource for the Chief Operations Officer for all external and internal compliance audits; ensures that corrective action plans are documented in a timely manner and effectively implemented. Oversees a corporate wide risk management program, develops and maintains a written corporate risk management plan and annual evaluation of the plans’ effectiveness. Develops and maintains policies and procedures related to the corporate risk management program. Develops and oversees processes for internal incident reporting and ensures timely entry into the software system. Reviews incident reports and ensures follow up investigations are completed as warranted. Reviews serious incident reports and collaborates with facility Risk Directors to ensure all incidents are reported appropriately. Collaborates with Facility Executive Leadership in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events; leads and/or participates in the development of root cause analyses. Oversees a corporate wide patient safety program, develops, and maintains a written patient safety plan and annual evaluation of the plan’s effectiveness and develops and maintains policies and procedures related to the patient safety program. Monitors all facility performance improvements initiatives. Participates in all Committee of the Whole meetings to ensure performance indicators are tracked, appropriate plans of action are developed and implemented, and the evidence of the meeting minutes meets all regulatory requirements. Oversees a continuous regulatory readiness program for all facilities that includes mock surveys and tracer activities. Assists facility on all regulatory surveys and collaboratively develops plans of correction. Monitors plans of correction to ensure ongoing compliance. Participates in the Electronic Health Record auditing process to ensure changing standards are continually met. Collaborates with the facility Risk Directors on the annual Ligature Risk Assessment and assists with updates as needed. And other duties as assigned. EDUCATION and/or EXPERIENCE: Master’s degree in Nursing, Social Work, Public Health, Healthcare Administration or bachelor’s degree and 2-3 years of experience working in the behavioral health field. ​​​​​ Demonstrated leadership skills including excellent oral and written communication skills. Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards. Strong knowledge of CQI tools and techniques, ability to perform data analytics, and lead performance improvement teams. Computer skills and knowledge of applicable software programs. Ability to work with diverse populations.