JOB SUMMARY: The Manager of Regulatory, QA, and Risk Management works collaboratively with senior
leadership, MMHS leaders, physicians and staff to reduce risk and promote quality patient care and safety.
This is accomplished through various assessment activities and process improvement actions through the
monthly Quality/Patient Safety Committee/Committee of the whole or ad hoc meetings. Manages and
coordinates efforts to ensure that quality management programs are developed and managed using a data
driven focus and sets priorities for improvements aligned to ongoing strategic imperatives. Ensures
compliance with Federal healthcare program requirements and facility’s risk management activities, which
include coordinating insurance coverage and risk financing, managing claims against the facility, interfacing
with defense legal counsel, administering the risk management program on a management education
programs and complying with the Joint Commissions risk management standards, all the objective of
controlling and minimizing loss to protect the assets of the facility.
This position exists 1) as a channel of communication to receive and direct compliance issues to appropriate
MMHS resources for investigation and resolution, and 2) as an internal resource with which concerned parties
may communicate after other formal channels and resources have been exhausted. Will work closely with
other management who are responsible for ensuring the organization complies with Joint Commission, Health
Insurance Portability and Accountability Act (HIPAA), and applicable accreditation standards.
Revised 12.20.2024
PERFORMANCE DIMENSIONS AND TASKS
Essential Function
1. On-going assessments of regulatory, quality assurance, and risk management, compliance policies and
procedures and assist in updating or developing new policies to enhance this positions’ areas of operations.
2. Carry out a vulnerability analysis on the organization’s Regulatory, QA, and Risk programs and activities,
discover areas of potential risk and vulnerability, and create and implement solutions to eliminate the potential
risks.
3. Develop and implement quality improvement initiatives.
4. Develop action plans and track progress.
5. Train staff on quality improvement processes.
6. Manage and direct healthcare training and educational programs to advance awareness and education of
potential Quality, Compliance risks, vulnerability, and reporting.
7. Supervise training in other laws such as the Physician Payment Sunshine Act, HIPAA, Stark Laws, and related
state/federal laws to ensure employees are informed on ethical and legal standards.
8. Tracks, reports and ensures the completion of action items resulting from compliance reviews. Analyzes and
investigates serious safety events in support of the patient safety program.
9. Conduct or delegate investigations, and coordinate internal and external corrective measures to be
executed.
10. Establishes and maintains a mechanism to track access to regulatory and risk information, within the
purview of the organization and as required by law to allow qualified individuals to review or receive a report
on such activities.
11. Stay informed of current legislation and enforcement issues affecting the healthcare industry, as well as
Regulatory, QA, and Risk Management best practices.
12. Prepare report for management on incidents, investigations, and all significant “breach” Regulatory, QA,
and Risk issues.
13. Carry out due diligence on new healthcare businesses/service before they are implemented and design
effective Regulatory, QA, and Risk integration plans.
14. Accurately, timely, and with due diligence will assist in the preparation and presentations for Joint
Commission and other related surveys reflecting compliance to clinical and non-clinical integration of
standards. Identifies deficiencies and assist in remedial resolution of such.
15. Responds to complaints and claims related to professional liability and transmits that information to the
insurance carrier of legal counsel. At the request of management, legal counsel, or the adjuster, participates in
responding to the complaint or claim to obtain information and facilitate settlement at an early stage. Works in
coordination with patient ombudsman or acts as same to resolve complaints before they develop into
professional liability claims.
16. Receives incident reports and other information regarding untoward occurrences in the facility, such as
quality assurance outline or variations, and collates such information systematically to permit analysis pursuant
to risk management policy and procedure. Reviews collated data to identify trends regarding accidents or
occurrences, and recommends corrective action to management if appropriate. Prepares reports to
management regarding data systems and findings.
17. All other duties as assigned
QUALIFICATIONS
Education :
Bachelor Degree in a healthcare related field – Required.
RN, JD, or MBA – Preferred.
Work Experience:
Minimum three years, recent full-time experience in managing a healthcare facility’s Regulatory,
Quality Assurance, and Risk Management – preferred.
Or, related experience in a Legal Department performing healthcare compliance work – Considered.
Proven knowledge of healthcare regulatory matters including:
a. Billing and coding, privacy and security, credentialing, and MMHS contracting; managed care
experience in Medi-Cal and Medicare highly preferred.
b. Laws relating to Medicare, Medicaid, EMTALA, HIPAA, the Stark Law, the False Claims Act, and the
Anti-kickback Statute. Knowledge of Managed care systems of a Knox-Keene licensed health
maintenance organization (HMO). Understanding and interpretation of State and Federal
regulations
Licensing Requirements:
Certification in Healthcare Compliance, Healthcare Compliance Fellowship, Healthcare Privacy
Compliance, Research Compliance, or other relevant areas – Obtained within one year of hire –
Required.
Current State License in a clinical field (five (5) years’ experience in Quality Management can be used
in lieu of state license). Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and
Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety
(CPQPS) within 2 years of employment. - Required
Language Requirements :
Must be fluent in English.
Physical Demands:
Must be able to sit and stand/walk for long periods of time.
Must be able to lift and carry up to 30 pounds.
Moderate exposure to hazardous waste and chemicals.
Special Demands:
Ability to supervise and work cooperatively with others.
Must be able to delegate duties and maintain efficient standards of operation.
Proficiency in Microsoft Office Suite.
Proficiency in quality improvement methodologies.
DISCLAIMER : The preceding job description has been designed to indicate the general nature and level of work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties,
responsibilities and qualifications required of employees assigned to this job.
