Job Summary:

Responsible for providing risk management counsel and oversight to prevent and control losses through proactive interventions and regulatory compliance in collaboration with the Vice President, Legal Affairs.  The Risk Manager focuses on facilitation of performance improvement activities, data analysis, risk assessment, coordination of loss control efforts, advising on potential sources of loss, supporting regulatory reporting functions and making recommendations for minimizing or eliminating risk exposure. The Ethics & Compliance Officer implements and manages the Corporate Ethics and Compliance Program (“Program”) for the organization in accordance with the Board of Trustees approved Plan.

Essential Functions:

• EDUCATES, ADVISES AND COUNSELS ON RELEVANT PATIENT, EMPLOYEE AND VISITOR SAFETY, RISK MANAGEMENT AND REULATORY ISSUES AFFECTING THE ORGANIZATION.

  • Actively participates on various committees, including but not limited to the Patient Safety, Infection Control, Health and Safety, Facilities, Emergency Management and Products Committees, as assigned.

• PROVIDES PROFESSIONAL LEVEL SUPPORT FOR THE ENTERPRISE RISK MANAGEMENT PROGRAM.

  • To prevent and/or minimize liability exposure, including event reporting, follow-up, investigation and processing of variance reports.

  • Reviews reports of incidents, serious events, infrastructure failures and other events entered by staff into the event reporting system.

  • Evaluates and trends events to identify opportunities for improvement in the delivery of patient care, the provision of services, employee safety and the environment and recommends follow-up action.

  • Provides investigational follow-up and research on problem specific events as may be assigned.

  • Supports Patient Safety and other departments in the classification of events in accordance with regulatory standards and the preparation of event reports for submission to the appropriate regulatory entities.

  • Performs risk assessments, assists in the grievance process and participates in environmental rounds.

  • Provides administrative support in development of reports, presentations etc.

• PARTICIPATES IN THE ESTABLISHMENT AND IMPLEMENTATION OF MANAGEMENT POLICIES AND PROCEDURES.

  • To prevent and control losses to patients, residents, clients, visitors, volunteers, and employees and to meet legal and regulatory requirements.

• COLLABORATES WITH INSURANCE COORDINATOR, V.P., LEGAL AFFAIRS, OUTSIDE LEGAL COUNSEL AND STAFF REGARDING POTENTIAL RISK EXPOSURE AFFECTING GSRN.

  • To assure that claims are promptly reported and managed.

  • Actively participates with GSRN Claims Management Team in the investigation, analysis, and disposition of claims.

• SERVES AS A RESOURCE FOR JOINT COMMISSION, DOH, CARF, ACREDITATION READINESS.

  • Participates in periodic facility audits; by educating staff on results; by alerting Senior Leaders to key findings and needed improvements.

  • Assists with scheduled and unannounced surveys/visits by licensing agencies and accrediting bodies.

• PARTICIPATES IN AND/OR CONDUCTS ROOT CAUSE ANALYSIS AND FAILURE MODE EFFECTS AND CRITICALITY ANALYSIS AS APPROPRIATE.

  • Responds to all serious/sentinel patient events in compliance with established policies and regulatory and insurance requirements and in conjunction with Patient Safety Plan. 

  • Assists in the identification of high volume/high risk processes and the facilitation of proactive analysis  and process improvement.

• COORDINATES WITH STAFF DEVELOPMENT/EDUCATION AND CLINICAL STAFF.

  • Develops and presents meaningful educational programs on clinical risk management/patient safety issues and loss prevention techniques for physicians and staff, and including orientation of new employees.

• IMPLEMENTS AND MANAGES THE BUSINESS ETHICS AND COMPLIANCE PROGRAM.

  • Performs the duties set forth in the Good Shepherd Rehabilitation Network Ethics and Compliance Plan established by the Board of Trustees and ensures that the Plan is followed.

  • Reports to the Executive Committee of the Board at least annually.

  • Chairs the Ethics and Compliance Committee.

  • Monitors the Compliance Line and event reports for compliance concerns or issues

  • Develops and/or reviews performance standards and policies.

  • Facilitates and/or oversees internal and external assessments of compliance.

  • Guides the development and implementation of corrective action plans, as needed.

  • Fields reports of actual or suspected ethics and compliance violations and investigates or delegates the investigation of such reports.

  • Recommends corrective action as needed in response to the substantiated ethics and compliance violations.

  • Serves as a resource for ethics and compliance questions.

• OTHER DUTIES AS ASSIGNED

  • Performs other duties as assigned by the organization consistent with its needs, employee's professional license/certification and demonstration of applicable competencies.