BWH - Compliance and Risk Manager

at  Bournewood Health Systems

ABOUT US:

Bournewood is committed to a philosophy and an environment of care in which we treat people with dignity, respect and mutuality; protect their rights; provide the best care possible; support them in returning to their natural communities; and include patients and families as partners in their treatment. Our philosophy stands for providing a safe and therapeutic environment for patients, families and staff in which restraint and seclusion are prevented through the use of a range of resources and tools. The incumbent is required to support this philosophy and guide staff in delivering trauma-informed care to the individuals we serve.
Job Summary:
Provides support to all levels of Bournewood Health Systems in maintaining compliance with Joint Commission, DMH, BSAS, CMS, HIPAA, and applicable laws. Promotes a culture of continuous Joint Commission/DMH survey readiness, works in collaboration with staff education and QI coordinator, educating and monitoring staff regarding the various standards and assuring that Policies/Procedures/Forms/Protocols reflect these standards. Maintains a tracking system for compliance data; analyzes data for use by the Leadership Team. Develops and oversees the facilities risk management programs, including patient safety, management of the facilities liability insurance policies, contract review in relation to compliance, incident reporting and analysis, and related programs. Oversees compliance with any corporate integrity agreements or memorandum of agreements.

Essential Functions:

• Provides assistance to departments and individuals in complying with Joint Commission, HIPAA, BSAS, CMS, and DMH Standards and other applicable laws as well as maintains current Joint Commission, DMH, BSAS, CMA, HIPAA, healthcare compliance and risk management skills through continuing education.
• Drafts and oversees management of Policies & Procedures, Forms, and Protocols, in relation to Compliance and Risk Management.
• Leads or assigns a designee for FMEA teams as well as leads or participates in inter-departmental Performance Improvement committees.
• Reviews the Accreditation, HIPAA, healthcare risk management and corporate compliance literatures, keeping relevant staff abreast of changes and developments, and recommending new initiatives.
• Operates as the Privacy Officer, developing and facilitating facility-wide compliance program for both HIPAA Privacy and Security Regulations.
• Develops and oversees the facility’s Risk Management Program, including Patient Safety and Ethics, and serves as the facility’s Risk Manager, orchestrating these activities in accordance with best practices and standards as well as prepares written and verbal reports to internal management groups and other entities as needed.

MINIMUM QUALIFICATIONS

• Minimum of Bachelor’s degree in a healthcare/related field or equivalent in training/experience.
• CPHRM preferred, LPN/RN preferred.
• Knowledge of Joint Commission, DMH, BSAS, CMS and HIPAA Standards, behavioral healthcare risk management, patient safety, and corporate compliance.
• Knowledge of contracts, and insurance preferred.
• Minimum of two years’ experience preferred.

Physical Criteria:

• Ability to use telephones extensively; ability to relay clear written messages; ability to use computer keyboard and calculator extensively.
• Ability to effectively read, write and process information; ability to input/retrieve information to/from computer and files.
• Ability to converse with others to give, take and process information; extensive use of telephone. Ability to hear alarms and pages.
• Ability to converse with others to give, take and process information; extensive use of telephone. Ability to maintain confidentiality of information, multi-task, coordinate projects and record/transcribe general and specific meeting minutes. Ability to work independently and collaboratively.
• Occasional/limited exposure to: Infection and to the risk of bloodborne diseases; hazardous agents, body fluids and wastes; unpleasant patient or departmental elements; to potentially violent/aggressive patients/staff/visitors, critical incidents, and/or sentinel events. Occasionally needed to work irregular hours or additional hours.

• Provides assistance to departments and individuals in complying with Joint Commission, HIPAA, BSAS, CMS, and DMH Standards and other applicable laws as well as maintains current Joint Commission, DMH, BSAS, CMA, HIPAA, healthcare compliance and risk management skills through continuing education.
• Drafts and oversees management of Policies & Procedures, Forms, and Protocols, in relation to Compliance and Risk Management.
• Leads or assigns a designee for FMEA teams as well as leads or participates in inter-departmental Performance Improvement committees.
• Reviews the Accreditation, HIPAA, healthcare risk management and corporate compliance literatures, keeping relevant staff abreast of changes and developments, and recommending new initiatives.
• Operates as the Privacy Officer, developing and facilitating facility-wide compliance program for both HIPAA Privacy and Security Regulations.
• Develops and oversees the facility’s Risk Management Program, including Patient Safety and Ethics, and serves as the facility’s Risk Manager, orchestrating these activities in accordance with best practices and standards as well as prepares written and verbal reports to internal management groups and other entities as needed