Director of Risk and Compliance

Position Summary

The Director of Risk & Compliance provides strategic leadership for the organization's Performance Improvement (PI), Regulatory Compliance, Accreditation, and Risk Management programs. This position ensures organizational compliance with HRSA Health Center Program requirements, federal and state regulations, and accreditation standards promoting a culture of continuous quality improvement across the organization. The Director partners with executive leadership, clinical leadership, operations, and department managers to improve enhance organizational performance, reduce risk, and ensure regulatory readiness. This person will work closely with the director of quality and nursing team as it relates to quality improvement, patient safety, and infection control.

Responsibilities

• Develop and implement the organization's Risk and Performance Improvement (PI) strategy
• Lead organization-wide Risk and Compliance initiatives
• Oversee compliance committees and multidisciplinary improvement teams
• Promote a culture of continuous improvement throughout the organization
• Serve as organizational lead for compliance with HRSA Health Center Program requirements including: HRSA Health Center Program Compliance Manual, Operational Site Visits (OSV), FTCA Risk Management requirements, program monitoring, HRSA reporting, corrective action plans, and federal grant compliance
• Coordinate HRSA Operational Site Visit preparation
• Maintain documentation supporting compliance
• Lead corrective action implementation following HRSA reviews
• Ensure ongoing readiness for HRSA site visits
• Ensure compliance with: CMS Conditions of Participation, HIPAA, DEA regulations, CDC recommendations, Massachusetts Department of Public Health regulations, and federal and state healthcare regulations
• Lead accreditation activities including: readiness assessments, mock surveys, policy review, staff education, survey coordination, corrective action planning, and continuous accreditation readiness
• Work closely with Clinical Quality & Patient Safety teams
• Oversee: patient safety reporting, Root Cause Analyses (RCA), Failure Mode and Effects Analysis (FMEA), sentinel event review, and near miss reporting
• Implement systems to improve: patient outcomes, access to care, care coordination, and patient experience
• Provide oversight for: enterprise risk management, clinical risk, incident reporting, adverse event investigations, patient complaints, medical record audits, infection prevention collaboration, and corrective action tracking
• Partner with legal counsel and insurance carriers regarding risk mitigation activities
• Develop dashboards that monitor: patient satisfaction, access metrics, financial quality indicators, and regulatory compliance indicators
• Use data analytics to identify trends and recommend improvement strategies
• Develop and maintain organizational policies
• Ensure policies reflect current federal and state regulations
• Coordinate annual policy review
• Monitor implementation and compliance
• Report to Board of Directors Policy and Procedure Committee
• Develop compliance education programs covering: regulatory updates, patient safety, incident reporting, infection prevention, HRSA requirements, Quality Improvement methodology, HIPAA, and risk management

Qualifications

• Bachelor's in Nursing or Public Health
• 5+ years working in compliance and quality role
• FQHC experience strongly preferred
• HRSA experience strongly preferred

Reporting Relationship: Chief Operating Officer