Job Summary
The Risk Manager is responsible for developing, implementing, and monitoring the Ambulatory Surgery Center (ASC) and Office Surgery Registration (OSR) risk management, patient safety, regulatory compliance, and quality improvement programs. This position ensures compliance with federal, state, CMS, AHCA, AAAHC, Joint Commission, OSHA, HIPAA, and other applicable regulations and accreditation standards.
The Risk Manager works collaboratively with physicians, nursing staff, administration, and department leaders to identify, investigate, and reduce organizational risk while promoting patient safety and quality outcomes.
Responsibilities
Essential Duties and Responsibilities Risk Management & Compliance
- Develops and maintains the ASC/OSR Risk Management Program.
- Conducts risk assessments and implements corrective action plans.
- Investigates incidents, adverse events, complaints, and near misses.
- Maintains incident reporting systems and trending analysis.
- Coordinates Root Cause Analysis (RCA) and follow-up activities.
- Ensures compliance with AHCA, CMS, OSHA, HIPAA, and accreditation standards.
- Assists with policy and procedure development and annual review.
- Monitors compliance with infection prevention and control standards.
- Maintains regulatory readiness for inspections and surveys.
- Coordinates emergency preparedness and safety programs.
Quality Improvement
- Participates in Quality Assessment and Performance Improvement (QAPI) activities.
- Tracks quality indicators and patient safety outcomes.
- Prepares reports for Quality Committee, Governing Body, and Medical Staff
- Identifies trends and recommends process improvements.
- Assists with credentialing and peer review activities as needed.
Staff Education & Training
- Provides education related to risk management, compliance, patient safety, and regulatory requirements.
- Coordinates mandatory training including:
- Fire safety
- Infection control
- HIPAA
- Emergency preparedness
- Active shooter response
- Workplace safety
- Educates staff on incident reporting procedures and documentation standards.
Patient & Employee Safety
- Promotes a culture of safety throughout the organization.
- Conducts environmental rounds and safety audits.
- Reviews infection surveillance reports and safety concerns.
- Collaborates with leadership regarding workers’ compensation and employee incidents.
- Assists with hazardous materials and exposure response management.
Documentation & Reporting
- Maintains confidential risk management files and documentation.
- Prepares regulatory reports and responses as required.
- Maintains logs related to incidents, safety drills, infection control, and compliance activities.
- Ensures timely reporting of sentinel events and required notifications.
Benefits:
Experience:
- Risk management: 5 years (Required)
License/Certification:
- Ambulatory Care Nursing Certification (Preferred)
Work Location: In person
