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CHC Career Opportunities

Director of Quality/Risk/Compliance

Wahiawa, HI
Organization:Wahiawa General Hospital
Career Type:Employee
Reports To:Chief Executive Officer at Wahiawa General Hospital
Role Description:

Under administrative direction, the Director of Quality/Risk/Compliance plans, organizes, directs, and coordinates various functions, operations and activities pertaining to risk assessment and compliance at Wahiawa General Hospital; develops, coordinates and administers systematic hospital risk assessment and compliance programs; develops and administers goals, objectives, policies, and procedures; participates in hospital-wide strategic development and planning processes; and performs other duties as assigned.


Distinguishing Characteristic:


This is a single-position class that reports to the Chief Executive Officer at Wahiawa General Hospital. The incumbent performs responsible and complex program management and administrative duties and serves as a member of the hospital’s executive management team to ensure that assigned programs, functions, and operations conform to organizational goals and objectives. Duties include significant responsibility for formulating and administering policies and procedures for assigned areas, as well as providing specialized management support and expertise to superiors. Assigned operations and functions include the planning, development, coordination, and administration of systematic risk assessment and compliance programs. The Hospital Risk Assessment and Compliance Director will work closely with the medical staffs and confer with the Chief Nursing Officer on issues related to Wahiawa General Hospital's risk and compliance programs and mitigation strategies.


Essential Functions - Quality Management Director

• Coordinate and attend all Medical Staff Committee meeting and all pertinent hospital committee meetings where monitoring functions and activities are performed.

• Serve as a resource for Medical Staff and internal services on quality improvement activities, education, and use of quality principles and tools.

• Direct the process of monitoring, measuring, and assessment of patient care and support of systems to achieve high quality, safe, cost effective healthcare services.

• Direct and provide oversight for the hospital Quality Assessment/Performance Improvement (QAPI) plan development, review, revision, and implementation. Coordinate and integrate QAPI plans and processes for individual services.

• Coordinate and report Medical Staff Quality Assurance/Improvement activities.

• Coordinate and manage Core Measures reporting and other functions.

• Collects and reports HCAHPS data for the facility functions.

• Facilitate PI teams as requested. Facilitate planning sessions as requested.

• Coordinate facility wide compliance with The Joint Commission and other regulatory agencies.

• Departmental oversight, payroll, budgets, education, schedules, supplies, policies, procedures, job descriptions.

• Share administrative call; participate in Executive Team duties and Leadership Team responsibilities. Act as chief administrative officer in the absence of the CEO, CFO and CNO.

• Provide oversight and supervision for quality management related functions: Patient Safety, Infection Control, Risk Management, and Medical Staff Affairs


Essential Functions - Risk Management Director

• Insurance/Risk Financing - Coordinates review and renewal of insurance policies.

• Claims management and Incident Reporting - oversight of the event and incident reporting systems, analyzes and responds to reports, compiles summaries of reports, reports potential claims to carriers, review patient/family/physician complaints for liability risk and resolution.

• Program Administration - Develops, coordinates, and administers hospital-wide systems for risk identification, investigation and reduction, maintains statistics, ensure that pertinent patient data relative to a claim is accurate, available, and secure. Reviews and coordinates trend analysis, claims profiles, worker's comp trends, and analysis of risk data. Advises security on loss reduction of property and assets. Develop, review and revise policies and procedures related to Risk Management.

• Legal Interface - Work with hospital legal counsel to coordinate the investigation, processing, and defense of claims. Responds to professional liability and hospital liability questions and maintains knowledge of legislative and regulatory activities related to health care risk management.

• Education - Provide in-service training to enhance awareness of employee's role in reducing liability exposures. Disseminate information on claim patterns and risk control, legislative and regulatory changes.


Essential Functions - Corporate Compliance Officer

• Establish Compliance Standards and Procedures in coordination with the Compliance Committee. Develop, implement, review, and revise the Corporate Compliance Plan. Coordinate the overall plan with individual plans for high risk areas, including coding and billing, laboratory, Home Health.

• Effectively communicate compliance standards, policies, and procedures to all employees, including administration, by training or dissemination of publications.

• Develop reasonable steps to ensure continuing compliance throughout the organization. Evaluate the program on an annual basis and implement steps for improvement.

• Report any apparent illegal activity or violations of the compliance policy to the Compliance Committee, the CEO, and the Board of Directors. Implement and enforce the disciplinary policy for violations.

• Maintain confidentiality to minimize the risk that any employee of the hospital feels any threat of retribution in reporting known or suspected wrongdoing. Maintains open and anonymous means of reporting or voicing concerns.

• Conduct periodic audits of individual hospital services and high-risk areas to ensure that they are in compliance with law, rules, and regulations.

• Oversight and coordination of the Corporate Compliance Committee. Maintains minutes and reports.

• Report at least annually to the Board of Directors.


• Baccalaureate degree in related area

• RN or other clinical degree/license preferred

• Knowledge of Professional Certification: CPHQ certification or will attain within three years of employment; CPPS certification or will attain within three years of employment. HACP or CJCP


• Minimum of 7 years of related work experience

• RN or other clinical degree/license preferred

• Knowledge of Professional Certification: CPHQ certification or will attain within three years of employment; CPPS certification or will attain within three years of employment. HACP or CJCP

• Strong record of leadership, project management, and team-building

• Strong communication skills, both written and speaking; ability to communicate with stakeholders at all levels of the organization and in a heavily diversified work environment


About Wahiawa General Hospital

Wahiawa General Hospital (WGH) in Wahiawa, HI. Wahiawa is on the main island of Oahu and is centrally located midway between Honolulu and the North Shore.


The Wahiawa Hospital Association was founded in 1944 in response to the healthcare needs of the community following the attack on Pearl Harbor. Several years later, Wahiawa General Hospital (WGH), a nonprofit, community hospital was established to further meet the growing needs of Central Oahu. WGH is centrally located on the island of Oahu, serving the surrounding communities of Central Oahu and the North Shore.


Today, the 53-bed acute facility and 107 beds in the long-term care facility are equipped for all levels of patient care. Their vision is clear: Wahiawa General Hospital is strengthening its role as the healthcare provider of choice for residents of Central Oahu and the North Shore.


Key Hospital Stats: 

Employees: 304

Total Discharges: 1,930

Total Patient Days: 8,804

Total Patient Rev. $112,267,059

Net Patient Rev. $46,903,255


About Community Hospital Corporation – HELP WHERE HOSPITALS NEED IT®

Community Hospital Corporation owns, manages and consults with hospitals through three distinct organizations – CHC Hospitals, CHC Consulting and CHC ContinueCARE, which share a common purpose to guide, support and enhance the mission of community hospitals and healthcare providers. Based in Plano, Texas, CHC provides the resources and experience community hospitals need to improve quality outcomes, patient satisfaction and financial performance.


Community Hospital Corporation (CHC) was named among 150 Great Places to Work in Healthcare by Becker’s Hospital Review in 2015 and 2016.


For more information about CHC, please visit www.communityhospitalcorp.com



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Advancing Community Hospitals for Two Decades