Bournewood Health Systems
Join to apply for the
Compliance and Risk Manager
role at
Bournewood Health Systems 2 days ago Be among the first 25 applicants Join to apply for the
Compliance and Risk Manager
role at
Bournewood Health Systems Description
The Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws. Description
The Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws.
The position promotes continuous regulatory readiness, supports the hospital’s Quality Improvement (QI) Plan, manages incident reporting and risk reduction activities, and provides education and consultation to staff and leadership regarding compliance and risk standards.
Essential Job Functions
Compliance & Accreditation
Serve as the hospital’s subject matter expert for regulatory standards, including: Joint Commission accreditation standards (Hospital Behavioral Health & Hospital Programs). CMS Conditions of Participation (psychiatric hospitals). DMH licensing regulations for inpatient psychiatric services. BSAS regulations for substance use disorder services. Maintain a system ofcontinuous survey readiness, including staff education, internal audits, and policy/procedure review. Develop and maintain compliance tracking systems to monitor performance against regulatory requirements. Draft, review, and oversee hospital policies, procedures, and protocols to ensure alignment with applicable standards and laws. Coordinate preparation for all regulatory and accreditation surveys and inspections. Oversee compliance with any Corporate Integrity Agreements (CIA), Memoranda of Agreement (MOA), or regulatory settlement agreements.
Risk Management
Develop and oversee the hospital’s Risk Management Program, including incident reporting, investigation, and analysis. Lead or assign staff to conduct Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA) as required by Joint Commission and DMH. Monitor trends in adverse events, complaints, and near misses; identify opportunities for system improvements. Ensure timely reporting of sentinel events, critical incidents, and other required notifications to regulatory agencies. Collaborate with leadership on insurance, liability claims, and contract review from a compliance and risk perspective. Prepare reports for leadership, the Quality Committee, and the Board of Directors on compliance, risk, and safety performance.
Quality Improvement (QI) Integration
Partner with the Quality Improvement Coordinator to support the hospital’s Performance Improvement Plan (PIP). Ensure risk management and compliance data are integrated into QI reporting. Monitor and analyze CMS quality reporting measures and Joint Commission quality indicators applicable to behavioral health. Lead or participate in interdepartmental Performance Improvement and Risk Committees. Promote a culture of accountability, transparency, and continuous improvement throughout the hospital.
Education & Consultation
Provide ongoing staff training on compliance, risk management, and regulatory standards. Keep leadership and staff informed of regulatory changes, survey outcomes, and improvement initiatives. Serve as a consultant to hospital departments in meeting compliance and risk management requirements.
Qualifications
Education:
Bachelor’s degree in Nursing, Social Work, or related healthcare field required. Master’s degree in Nursing, Social Work, Healthcare Administration, or related field strongly preferred.
Licensure/Certification:
Current LICSW, RN, or LPN required. Certification in Healthcare Risk Management (CPHRM) or Healthcare Compliance (CHC) preferred.
Experience:
Minimum 3 years’ experience in compliance, risk management, or quality improvement in a healthcare setting (psychiatric or behavioral health preferred). Demonstrated knowledge of: Joint Commission Behavioral Health & Hospital Accreditation Standards CMS Conditions of Participation for Psychiatric Hospitals DMH licensing regulations BSAS standards (if applicable to program areas) Experience with incident investigation, regulatory reporting, and corrective action planning. Familiarity with insurance and healthcare contracts preferred.
Core Competencies
Regulatory Knowledge: Expert understanding of psychiatric hospital accreditation and licensing standards. Decision-Making: Ability to make sound, ethical, and compliant decisions within scope of authority. Communication: Strong written and verbal communication skills; ability to provide clear education and consultation. Analytical Skills: Skilled in data collection, analysis, and presentation to leadership. Leadership: Ability to lead committees, facilitate cross-departmental collaboration, and influence culture. Confidentiality: Maintain the highest standards of confidentiality and integrity in handling sensitive information.
Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
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Compliance and Risk Manager
role at
Bournewood Health Systems 2 days ago Be among the first 25 applicants Join to apply for the
Compliance and Risk Manager
role at
Bournewood Health Systems Description
The Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws. Description
The Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws.
The position promotes continuous regulatory readiness, supports the hospital’s Quality Improvement (QI) Plan, manages incident reporting and risk reduction activities, and provides education and consultation to staff and leadership regarding compliance and risk standards.
Essential Job Functions
Compliance & Accreditation
Serve as the hospital’s subject matter expert for regulatory standards, including: Joint Commission accreditation standards (Hospital Behavioral Health & Hospital Programs). CMS Conditions of Participation (psychiatric hospitals). DMH licensing regulations for inpatient psychiatric services. BSAS regulations for substance use disorder services. Maintain a system ofcontinuous survey readiness, including staff education, internal audits, and policy/procedure review. Develop and maintain compliance tracking systems to monitor performance against regulatory requirements. Draft, review, and oversee hospital policies, procedures, and protocols to ensure alignment with applicable standards and laws. Coordinate preparation for all regulatory and accreditation surveys and inspections. Oversee compliance with any Corporate Integrity Agreements (CIA), Memoranda of Agreement (MOA), or regulatory settlement agreements.
Risk Management
Develop and oversee the hospital’s Risk Management Program, including incident reporting, investigation, and analysis. Lead or assign staff to conduct Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA) as required by Joint Commission and DMH. Monitor trends in adverse events, complaints, and near misses; identify opportunities for system improvements. Ensure timely reporting of sentinel events, critical incidents, and other required notifications to regulatory agencies. Collaborate with leadership on insurance, liability claims, and contract review from a compliance and risk perspective. Prepare reports for leadership, the Quality Committee, and the Board of Directors on compliance, risk, and safety performance.
Quality Improvement (QI) Integration
Partner with the Quality Improvement Coordinator to support the hospital’s Performance Improvement Plan (PIP). Ensure risk management and compliance data are integrated into QI reporting. Monitor and analyze CMS quality reporting measures and Joint Commission quality indicators applicable to behavioral health. Lead or participate in interdepartmental Performance Improvement and Risk Committees. Promote a culture of accountability, transparency, and continuous improvement throughout the hospital.
Education & Consultation
Provide ongoing staff training on compliance, risk management, and regulatory standards. Keep leadership and staff informed of regulatory changes, survey outcomes, and improvement initiatives. Serve as a consultant to hospital departments in meeting compliance and risk management requirements.
Qualifications
Education:
Bachelor’s degree in Nursing, Social Work, or related healthcare field required. Master’s degree in Nursing, Social Work, Healthcare Administration, or related field strongly preferred.
Licensure/Certification:
Current LICSW, RN, or LPN required. Certification in Healthcare Risk Management (CPHRM) or Healthcare Compliance (CHC) preferred.
Experience:
Minimum 3 years’ experience in compliance, risk management, or quality improvement in a healthcare setting (psychiatric or behavioral health preferred). Demonstrated knowledge of: Joint Commission Behavioral Health & Hospital Accreditation Standards CMS Conditions of Participation for Psychiatric Hospitals DMH licensing regulations BSAS standards (if applicable to program areas) Experience with incident investigation, regulatory reporting, and corrective action planning. Familiarity with insurance and healthcare contracts preferred.
Core Competencies
Regulatory Knowledge: Expert understanding of psychiatric hospital accreditation and licensing standards. Decision-Making: Ability to make sound, ethical, and compliant decisions within scope of authority. Communication: Strong written and verbal communication skills; ability to provide clear education and consultation. Analytical Skills: Skilled in data collection, analysis, and presentation to leadership. Leadership: Ability to lead committees, facilitate cross-departmental collaboration, and influence culture. Confidentiality: Maintain the highest standards of confidentiality and integrity in handling sensitive information.
Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
Job function Finance and Sales Industries Hospitals and Health Care Referrals increase your chances of interviewing at Bournewood Health Systems by 2x Get notified about new Risk Manager jobs in
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