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Quality and Risk Manager 


Job Summary

The Quality and Risk Manager develops and administers risk-management and loss-prevention programs and manages the staff within the program. Initiates policies to comply with safety legislation and industry practices. Will research and report on enhancing and promoting patient safety, quality care, and minimizing loss to protect the assets of the facility. Will be responsible for complying with all standards of the Accreditation Association for Ambulatory Healthcare Centers (AAAHC) and other regulatory agencies, including other accreditation agencies. Incumbent shall also manage and oversee the Facilities program and Security personnel. All duties and responsibilities will be performed in accordance with the Yellowhawk Mission and Vision statements, policies and relevant laws.

Essential Job Functions:

  1. Complies with risk management related standards of the AAAHC and other accrediting and regulatory agencies with an emphasis on enhancing and promoting patient safety, quality care, and minimizing loss to protect the assets of the facility.
  2. Serves as AAAHC Accreditation Coordinator and is responsible for directing and monitoring efforts at YTHC towards ongoing AAAHC accreditation. Also coordinates and assists with other accreditations, such as but not limited to, PCPCH and PHAB.
  3. Responsible for the day-to-day managing and analyzing of risk, and interacting with employees, patients and visitors regarding complaints and grievances.
  4. Responsible for formulating policy, providing staff and/or community education, public relations and social media, quality improvement and developing strategies and implementing quality improvement projects.
  5. Updates and maintains policy management software.
  6. Updates and maintains health related training program and/or software.
  7. Complies with, and is responsible for, the Yellowhawk Risk Management Program Policies and Procedures.
  8. Reviews, revises and develops policies and procedures to current best practice, legislative and regulatory standards.
  9. Create, implement, and maintain a Risk Communication Plan, emergency communication protocol, and Quality Improvement Plan per Yellowhawk and accreditation requirements.
  10. Coordinate and collaborate with the Public Health Emergency Preparedness Coordinator on a Yellowhawk-wide Emergency Operations Plan (EOP) and Continuity of Operations Plan (COOP).
  11. Conducts a risk assessment, at a minimum, every two years to identify potential hazards, vulnerabilities, and resources.
  12. Chairs the Quality Improvement Program Team and Risk Management Committees.
  13. Ensures that Peer Reviews are completed regularly and on time.
  14. Tracks, investigates, analyzes, and responds to all feedback and safety events and in a timely and accurate manner.
  15. Develops and implements corrective action plans for problems uncovered by risk assessments, audits and investigations.
  16. Analyzes and reports the effectiveness of corrective action plans in preventing future risk.
  17. Responds to all emergency (Code) calls throughout the facilities on the campus and provides a summary report for all calls to the Risk Management Committee.
  18. Routinely collaborates with Yellowhawk management to assess the current state of patient safety and staff awareness within the organization. Has understanding an experience with Incident Command.
  19. Conducts regular training and drills, individual or group, for staff and/or community in prevention programs that may include, but are not limited to, emergencies (including using an incident command system), risk management reporting (ex: Quantros), patient safety, employee health, compliance with regulatory standards (ex: OSHA), emergency preparedness, accident reporting and prevention, privacy standards (ex: HIPAA). Also includes developing a process for and conducting regular response exercises.
  20. Provide and document just-in-time training for individuals involved in response activities; as well as create and document After Action Reports (AAR) for drills, exercises and real emergency response events. Implement all necessary improvements based on the results of the AARs.
  21. Coordinates and collaborates with tribal, county, State and Federal partners to ensure health and security, preparedness and response is met during state of emergencies.
  22. Notifies appropriate Yellowhawk staff immediately of developments involving liability or litigation.
  23. Maintains Employee Health record and ensures compliance with required employee vaccinations and screenings.
  24. Develops and implements the budget for the program per the fiscal management policies.
  25. Supervises, directs, counsels, trains and all other management aspects, all staff within the program.
  26. Shall oversee and be responsible for the daily operations of the Security personnel; includes developing and implementing a comprehensive safety program for Yellowhawk.
  27. All other duties as assigned.
Position Requirements

Minimum Qualifications:

  1. Master’s degree in Healthcare, Business, Risk Management, or related field. with 2 years of successful experience relevant to this position;


Bachelor’s degree in Healthcare, Business, Risk Management, or related field. with 4 years of successful experience relevant to this position;


Associates degree in Healthcare, Business, Risk Management, or related field. with 6 years of successful experience relevant to this position;

  1. 3 years of successful supervisory experience.
  2. Demonstrated experience with computer software – e.g. Microsoft Office, Healthcare Software and Compliance software.
  3. Demonstrated ability to communicate effectively, both in writing and oral, in any situation, with peers, staff, management, local, state and federal agencies and the general public, on various topics including but not limited to policies, procedures, memoranda and training materials.
  4. Demonstrated knowledge and experience with safety/risk rules and regulations, including but not limited to OHSA and AAAHC.
  5. Demonstrated experience with regulatory risk, including how to prevent, identify, assess and eliminate risks and liabilities in the workplace.
  6. Demonstrated experience with conducting investigations, data collection and reporting.
  7. Demonstrated experience with policy development.
  8. Experience serving as a liaison between groups within an organization, as an effective member of organizational teams and in coordinating software implementation projects.
  9. Extensive knowledge of a broad range of patient care activities, working knowledge of an outpatient, multidisciplinary environment and how the different services and functions interact.
  10. Demonstrated experience in budget development and implementation.
  11. Must have and maintain CPR training certification.
  12. Must possess the ability to handle conflict and crisis in a professional manner.
  13. Must possess a valid state driver’s license and meet and maintain Yellowhawk insurance requirements.
  14. Must submit to and pass a reference and criminal background check.
  15. Must submit to and pass a pre-employment drug and alcohol screening.
  16. Must provide proof of COVID-19 vaccinations.

Preferred Qualifications:

  1. Professional Risk Manager License or Certification
  2. Certification in Healthcare Risk Management is preferred.
  3. Experience with Incident Command systems
  4. Experience in a Tribal Healthcare system.
  5. Experience with accreditation.
  6. Experience and/or knowledge of history, culture and health needs of Native American communities preferred.
Closing Date September 07, 2023 at 4:00 PM  
Supervised By Chief Executive Officer  
Salary $78,966.67-$118,513.75 OR $90,845.67 -$136,279.13  
Covered Status NO  
Safety Sensitive NO  
EOE Statement No employee or job applicant shall be discriminated against in the pursuit of employment due to Race, Color, Religion, Sex or National Origin or any other category protected by law, except as provided by the Indian Preference Act under Title 25, of the U.S.C.  

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