The Risk Management, Safety and Compliance Specialist oversees CCHC’s risk management program and safety initiatives. This position provides leadership, direction and facilitation of policies and procedures and activities related to risk management and safety. This position also provides compliance oversight for CCHC’s 340B program.
DUTIES AND RESPONSIBILITIES
Risk and Safety
- Responsible for overseeing and implementing CCHC’s risk management plan and daily risk management activities.
- Champion a culture of safety awareness and risk management prevention throughout the organization
- Work in conjunction with other staff identified as subject matter experts to accomplish agency risk management and safety goals
- Create and/or coordinate the creation of policies and procedures to reduce overall risk; ensure implementation and monitor; ensure alignment with all federal/state/local regulations and funding sources requirements
- Chair agency’s Risk Management Committee and chair/participate in other committees related to risk, safety and quality as assigned; serves as the agency’s Safety Captain
- Oversee completion of risk and safety assessments; complete, track and report monthly, quarterly and annual risk assessment/management activities with programs/departments
- Follow up with managers regarding monitoring and tracking program/department risk management initiatives/projects, goals and action planning
- Monitor the performance and outcomes for risk and safety, initiatives, corrective action plans and goals; prepare quarterly reports of outcomes
- Create, implement and maintain workflows and standard operating procedures (SOPs)
- Complete internal risk and safety walkthroughs/inspections and audits at agency sites; implement interventions to ensure compliance and reduce overall risk
- Track, analyze, and communicate risk and safety incident trends, including near misses and adverse events; make recommendations for areas of improvement; Track, follow up and report on incident reporting and grievances (monthly, quarterly and annually)
- Coordinate, schedule, and/or instruct safety-training including course curriculum and materials.
- Develop and execute emergency plans; collaborate with safety captains/co-captains and on-site supervisors and drills (i.e. fire, tornado, agency safety codes)
- Develop and execute safety awareness campaigns
- Implement and track federal Centers for Medicare and Medicaid (CMS) Emergency Preparedness (EP) Rule requirements
- Participate in local and regional EP networks and meetings
- Conduct regular agency and site-specific safety meetings across all departments
- Oversee the tracking and reporting of employee safety training records
- Ensure all incident/accident/injury reports are completed accurately and distributed to the proper channels by assisting management with investigation and reporting
- Ensures organizational compliance with OSHA, Health Resources and Services Administration (HRSA), Federal Tort Claims Act (FTCA) and all federal, state and local funding/monitoring sources
- Develop a thorough understanding of the 340B Program and improve the overall efficiency, value, and internal support of the 340B Program; obtain 340B training/certification
- Maintain 340B operational compliance and policy and procedures for the 340B program, program enhancement/optimization and reporting with federal regulations; complete risk assessment and program audits
- Develop systems and processes to limit program liabilities and provide proper audits to identify risk and prevent duplicate discounts and diversion for 340B Program.
- Facilitate the monthly 340B committee to discuss compliance, program updates, eligibility and other quality assurance related subject matters. Provide proactive education to staff on policies and procedures related to inventory management and 340B procedures.
- Develop proper 340B quality assurance training for employees as appropriate.
Other Quality Duties
- Assist with FTCA application completion and activities
- Participate in Uniform Data Systems (UDS), HRSA and other record reviews as identified
- Assist with national recognition/accrediting body (i.e., Patient Centered Medical Home), HRSA operational site visit, and other identified activities
- Complete annual risk and quality trainings including ECRI risk management certificate program
- Collaborate with supervisor on other risk, quality and compliance related projects/activities and reporting
- Complete departmental and agency reports as directed/needed
Minimum of a Bachelor’s Degree in Social Work, Human Services, Public Health, Health, IT, Health Administration or related field; Prior health care and social services experience preferred. Knowledgeable about federal, state and local standards/guidelines related to risk management (RM), Occupational Safety and Health Administration (OSHA), compliance, and quality assurance (QA). Strong organizational, verbal and written communication, and analytical skills. Experience with Microsoft applications (Word, Excel, and Power Point) required. The ability to function objectively in monitoring, tracking and assessing program services and maintain confidentiality.