The information described in this job description has been designed to indicate the general nature of the 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.
Other information:
Job Summary
The Regional Director of Risk Management, Compliance, and Patient Safety is responsible for developing, implementing, and overseeing an integrated framework that promotes regulatory compliance, mitigates organization risk, and advances a culture of safety across the healthcare system. The healthcare system includes complex joint ventures and operating of entities through third-party operating agreements. This role provides strategic direction and operational leadership to ensure the organization meets all federal, state, and local regulatory requirements while proactively identifying and reducing clinical, operational, and financial risks. This position ensures the Board of Commissioners, management and employees of SRH achieve consistently high levels of compliance with all laws and regulations while supporting the growth of SRH. Reporting directly to the Chief Quality Officer, the Regional Director partners closely to design and execute system-wide safety strategies, event reporting programs, and further actively supports root cause analyses and continuous improvement initiatives that enhance clinical outcomes and patient experience. For Risk Management and Compliance matters, the role reports with a dotted line to the Chief Executive Officer.
Essential Functions
Develops and implements regional risk management, compliance, and patient safety strategies aligned with system-wide goals. Serves as a key advisor to executive leadership on risk exposure, regulatory changes, and safety trends. Directs identification, assessment, and mitigation of clinical and operational risks. Creates and oversees SRH Risk Management Plan. Oversees claims management, litigation support, and collaboration with legal counsel and insurers throughout the claims process. Guides defense strategy for defense. Facilitates discovery process. Supports providers and staff during claims process. Attends and participates in alternative dispute resolution events to include mediation and arbitration sessions. Attend depositions, deposition preparatory sessions and trial. Advises finance on claim reserves in relation to limits and uninsured claims. Analyzes adverse events, near misses, and liability trends to reduce preventable harm. Responsible for organizational insurance program components including professional liability, general liability, workers’ compensation, property and causality, cyber, active assailant and other identified needs ensuring compliance with state requirements and Medicare and Medicaid regulations. Partners with brokers to identify and evaluate insurance markets and options, effectively allocating risk through the purchase of commercial insurance policies. Negotiates and reviews insurance policies. Performs risk review of all policies and procedures. Keep abreast of current risk management trends and developments. Serves as the Chair of SRH’s Corporate Compliance Committee. Creates and oversees SRH Compliance Plan and Program. Ensures compliance with applicable federal and state laws and regulations. Responds to alleged violations of rules, regulations, policies, procedures, and SRH code of conduct by evaluating or recommending the initiation of investigative procedures. Performs independent reviews, audits and evaluations of compliance organizations to ensure resolution. Ensures violations or potential violations are properly and timely reported to duly authorized enforcement agencies as appropriate and/or required. Leads efforts in developing response plans for compliance investigations. Oversees development and enforcement of policies and procedures and compliance training. Develops and oversees a system for uniform management of allegations of violations. Monitors anonymous compliance hotline and email. Leads patient safety programs. Chairs patient safety committee. Creates and oversees SRH Patient Safety Plan. Serves as SRH representative with PSO’s (ECRI/ISMP & WSHA NWSQ). Backup root cause analyses (RCAs) resource. Implement evidence-based safety initiatives to improve clinical outcomes and reduce harm. Monitors and reports key safety and quality metrics. Maintains current knowledge of applicable federal and state laws standards. Ensure organizational adaptation and compliance. Consults with legal counsel on organizational liability, litigation, arbitration and mediation. Responsible for oversight of SRH’s third-party (non-payer contracts) system, to include review, approval and performance monitoring. Promotes a just culture environment that encourages reporting and transparency. Provides education and training on compliance, risk prevention, and patient safety best practices. Partners with clinical and operational leaders to embed safety principles into daily practice. Support SRH leadership and staff by educating and advising on risk and legal topics and questions that arise. Utilizes data analytics to identify trends, measure program effectiveness, and drive performance improvement. Prepare reports and dashboards for executive leadership and governing boards. Collaborates with clinical leadership, legal, HR, and quality teams to ensure integrated risk and compliance oversight. Serves on committees related to risk, safety, and compliance. Supports board-level reporting and governance responsibilities. Co-chairs the SRH Policy and Procedure Committee. Supports SRH Public Records Request compliance. Ensures that behavior by employees, Commissioners, volunteers, students, contractors and vendors within the organization meets Skagit Regional Health’s Code of Conduct and complies with SRH’s policies and procedures. Complete all mandatory learning requirements in a timely manner. Perform other duties as assigned.
Education
A Bachelor’s degree required; Master’s degree highly preferred.
Experience/Training
A minimum of 10 years’ experience in a healthcare organization, to include demonstrated leadership, programmatic development and successful administration of the compliance program in an acute care organization. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations required.
License/Certifications
None required. CPHRM preferred.
Other Skills
The Director of Compliance and Risk will have skills and experience to identify potential compliance issues, remain objective, function independently, highly detail oriented and experienced in investigative and reporting procedures. Demonstrated leadership and ability to communicate effectively orally and in writing. Familiarity with and working knowledge of healthcare laws, regulations, and standards and understanding of coding and reimbursement systems, contracting, information systems, risk management, and performance improvement. Thoroughly understands legal defense, depositions, production of documents and Interrogatories.
Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for long periods of time, when working in office. Repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems most of the day is a function of the position. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position requires working in an indoor, environmentally controlled environment when in the office.
Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.
