DIRECTOR - RISK MANAGEMENT
Universal Hospital Services Inc., Raleigh, North Carolina, United States, 27601
Responsibilities
About Universal Health Services
One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
Qualifications POSITION SUMMARY
The Facility Risk Manager (FRM) has broad responsibility to protect the hospital's assets from loss. The FRM is responsible for coordinating loss control efforts and advising management and administration on all potential sources of loss and for making recommendations to minimize or eliminate exposure. The structure and functions of the Risk Management Program are designed to comply with guidelines and standards of TJC, other regulatory agencies, and the UHS T.E.R.M.© Program. The Facility Compliance Officer (FCO) has broad responsibility to always ensure the hospital’s compliance with the UHS Code of Conduct and Compliance Program policies.
QUALIFICATIONS
Education:
Bachelor’s Degree from an accredited college or university required. Bachelor’s Degree from accredited college or university in nursing, or related health field is preferred. Master’s Degree preferred. Combination of education and experience considered.
Experience:
Four (4) years of experience in quality and risk management/improving organizational performance within an acute medical or psychiatric treatment setting.
Additional Requirements:
Strong knowledge of Joint Commission, state of North Carolina standards, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.
Standards of Performance
Responsibility I: Risk Identification and Evaluation
Ensures appropriate and timely reporting of occurrences by maintaining a Healthcare Peer Review Reporting system; enters incidents into the MIDAS Database.
Collects and screens all reports.
Analyzes and trends data.
Identifies actual and potential risk situations and facilitates the determination of causative factors.
Refers occurrences for follow‑up to appropriate department or medical committee; ensures that all Level III/IV are referred to the CRM and PCR entered STARS within ten days.
Receives immediate and concurrent reporting of adverse patient outcomes identified by the PI process.
Performs risk surveys and inspects patient care areas in concert with hospital's safety (EOC) program committee objectives.
Reviews reports on facility and equipment to assess potential loss.
Receives and investigates reports of product problems to determine appropriate responses and establish record‑keeping responsibilities. In the event of patient injury, establishes direction from Corporate Risk Management in the appropriate action for defense strategy.
Receives information (verbally or formally on the HPR) from facility staff regarding patient events which may lead to a claim.
Responsibility II: Risk Reduction
Networks with department directors to implement system changes aimed at optimally reducing or eliminating causative factors.
Networks with medical staff to ensure active involvement and participation in:
Risk identification
Risk analysis
Risk reduction/loss prevention problem solving and program development designed to benefit the clinical aspects of patient care and safety.
Networks with medical staff to ensure the credentialing and privilege delineating process requires information regarding professional liability experience, results of peer review activities, changes in medical staff memberships, clinical privileges, licensure, etc.
Interfaces with the Patient Advocate specific to patient complaints and assesses/recommends action, on those, which may be a source of potential litigation.
In conjunction with hospital administration recommends actions, when possible, to resolve with patient and/or family any grievances against hospital perceived as potential liability claims.
Refers policies that present particular risk in relation to previously identified problems to Corporate Risk Management.
Identifies particular practices having legal connotations to target planning of preventive and corrective measures.
Assesses liability and probability of legal action.
Is available to resolve treatment issues, including patient refusal of treatment, consent issues, HIPAA violations, AMA's, etc. under direct supervision of CEO, Corporate Legal Counsel, and Corporate Risk Management.
Responsibility III: Performance Improvement
Ensure the hospital meets Joint Commission, CMS, and state regulatory requirements.
Develop and implement a Performance Improvement Plan, evaluate the results monthly and report the results to PI Committee, MEC and BOG.
Ensure that all deficiencies identified through the Performance Improvement analysis are addressed with appropriate problem‑solving actions.
Analyze statistical data of the hospital to determine and respond to trends.
Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, CMS, TDSHS, OSHA regulations and all other applicable federal, state or local law/regulations governing health‑care entities.
Responsibility IV: Claims Management
Assists CEO in facilitating the processing of summons and complaints served on the hospital and its employees.
Reports receipt of summons and complaints immediately to Corporate Risk Management and Insurance Department.
Assists the Corporate Risk Management as needed to intervene, document and assist in the investigation of all claims.
Coordinates investigation of claims within the facility:
Directs in‑house claims investigation.
Preserves all pertinent information (medical record, x-rays, equipment, lab/pathology specimens, relevant reports/ policies and procedures).
Facilitates early reporting.
Establishes early control of situation.
Assists in obtaining materials for attorneys.
Maintains all legal case files and ensures maximum protection and discoverability.
Coordinates with and assists attorneys as they interface with the facility and employees.
Advises Business Office of actions consistent with directions from Corporate Office for unpaid accounts involved in litigation.
Responsibility V: Compliance Program
Conducts/facilitates in‑services to educate employees and physicians.
Participates in developing/reviewing policies and procedures.
Operates to maintain and facilitate systems ensuring hospital and employee adherence to UHS Compliance Program.
Responsibility VI: Committee Participation
Performance Improvement
Patient Safety Council
Peer Review
Environment of Care/Safety
Medical Staff Committee
Utilization Review
Credentials
Pharmacy & Therapeutics
Infection Control
Board of Governors
Other Committees/Meetings as necessary
Responsibility VII: Employee/Physician Education
Facilitates, develops, and provides educational programs to ensure all employees and medical staff are aware of the Risk Management/PI/Compliance concepts and its relation to their specific duties/job role in identifying and reducing liability exposures.
Plans and presents risk management/performance improvement and compliance information to all new employees at hospital orientation.
Plans and presents risk management/performance improvement and compliance information to all employees at annual update.
Plans, presents, facilitates, and/or recommends in‑services to all departments as necessary to address risk management/performance improvement and compliance problems.
Submits articles to hospital, nursing, medical staff newsletters, as appropriate.
Plans and presents in‑services/information at Department Managers meetings. Provides Risk Manager presentation specific to management levels at least annually.
Shares current literature and articles of relevance with all appropriate departments.
Plans, facilitates, presents information and suggests topics on risk management/performance improvement and compliance to Committees or hospital departments as necessary and based upon occurrences or claim patterns.
Responsibility VIII: Reporting, Report Preparation and Submission
Provides aggregate analysis of risk and performance improvement data and trend analysis of incidents to:
Administration
Corporate Risk Management
Patient Safety Council
MEC
Performance Improvement
Environment of Care/Safety Committee (Safety related only)
Governing Board
Other Committees/Department as necessary and related to the department
Incidents with Potential Claims:
Directly reports to Administration those incidents with claims potential.
Reports to Corporate RM any serious risk event involving actual or potential injury to patients and visitors; enters PCR’s (Level III/IV incidents) into STARS Database within 10 business days of the incident.
Responsibility IX: Medical Staff
Advises the Medical Director and Medical Executive Committee as needed.
Serves as a resource to the Medical Staff Credentialing Process and the Credentials Committee as needed. Data from physician peer review and risk management activities are utilized in the decision making process of granting privileges to and reappointment of medical and allied health staff.
Develops, coordinates, presents/facilitates educational programs specific to medical staff concerns.
Advise physicians on issues of interest or concern including Informed Consent process, Documentation and communication; Accountability; Response to patient/family complaints; and internal problem solving.
Provides methods to communicate patient events to the Facility Risk Manager that may result in a claim.
Responsibility X: Professional Growth and Development
Consults with Medical Director as necessary.
Regularly reviews current literature pertinent to Risk Management and Regulatory Agency Requirements.
Attends appropriate management and risk management seminars.
Consults with Corporate Risk Management as necessary.
Responsibility XI: Guest Relations
Demonstrates tact, diplomacy, and sensitivity in communications.
Is clear and accurate in communication.
Responds promptly to requests, problems, and questions.
Maintains confidentiality as appropriate.
Interacts well with co‑workers, inter and intra departments.
Note:
The essential job functions of this position are not limited to the duties listed above.
Knowledge, Skills, and Abilities
Knowledge of Joint Commission, CMS, TDSHS and all federal and state laws/regulations.
Knowledge of quality management principles, practices and techniques.
Knowledge of performance improvement planning techniques and goals.
Knowledge of computers and various software.
Strong analytical interpretation skills.
Skill in organizing and prioritizing workloads to meet deadlines.
Skill in telephone etiquette and paging procedures.
Effective oral and written communication skills.
Ability to communicate effectively with patients and co‑workers.
Ability to adhere to safety policies and procedures.
Ability to use good judgment and to maintain confidentiality of information.
Ability to work as a team player.
Ability to demonstrate tact, resourcefulness, patience and dedication.
Ability to accept direction and adhere to policies and procedures.
Ability to recognize the importance of adapting to the various patient age groups (child, adolescent, adult and geriatric).
Ability to work in a fast‑paced environment.
Ability to meet corporate deadlines.
Ability to react calmly and effectively in emergency situations.
Ability to supervise personnel.
Physical, Mental, and Special Demands
Ability to work at least 40 hours per week, and flexible hours and overtime as required.
Ability to sit for long periods, up to 8 hours.
Ability to use both hands in fine and gross manipulation of small tools (copier, computer, telephone, calculator, facsimile machine).
Ability to push and pull up to 10 lbs.
Ability to communicate clearly and see well enough to read handwritten and typewritten material.
Ability to lift and carry up to 25 lbs. dead weight.
Ability to stop and bend daily.
Ability to reach, turn, and twist above and below the waist daily.
Ability to stand and walk the facility daily.
Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical for business office atmosphere.
Ability to handle a variety of repetitive tasks at a moderate level.
Prepared to occasionally handle electrical, mechanical, or equipment emergencies.
Machines, Tools, Equipment, and Other Work Aides
Computer system and printer.
Calculator/10‑key
Telephone and paging system.
Copy machine.
Fax.
#J-18808-Ljbffr
One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
Qualifications POSITION SUMMARY
The Facility Risk Manager (FRM) has broad responsibility to protect the hospital's assets from loss. The FRM is responsible for coordinating loss control efforts and advising management and administration on all potential sources of loss and for making recommendations to minimize or eliminate exposure. The structure and functions of the Risk Management Program are designed to comply with guidelines and standards of TJC, other regulatory agencies, and the UHS T.E.R.M.© Program. The Facility Compliance Officer (FCO) has broad responsibility to always ensure the hospital’s compliance with the UHS Code of Conduct and Compliance Program policies.
QUALIFICATIONS
Education:
Bachelor’s Degree from an accredited college or university required. Bachelor’s Degree from accredited college or university in nursing, or related health field is preferred. Master’s Degree preferred. Combination of education and experience considered.
Experience:
Four (4) years of experience in quality and risk management/improving organizational performance within an acute medical or psychiatric treatment setting.
Additional Requirements:
Strong knowledge of Joint Commission, state of North Carolina standards, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.
Standards of Performance
Responsibility I: Risk Identification and Evaluation
Ensures appropriate and timely reporting of occurrences by maintaining a Healthcare Peer Review Reporting system; enters incidents into the MIDAS Database.
Collects and screens all reports.
Analyzes and trends data.
Identifies actual and potential risk situations and facilitates the determination of causative factors.
Refers occurrences for follow‑up to appropriate department or medical committee; ensures that all Level III/IV are referred to the CRM and PCR entered STARS within ten days.
Receives immediate and concurrent reporting of adverse patient outcomes identified by the PI process.
Performs risk surveys and inspects patient care areas in concert with hospital's safety (EOC) program committee objectives.
Reviews reports on facility and equipment to assess potential loss.
Receives and investigates reports of product problems to determine appropriate responses and establish record‑keeping responsibilities. In the event of patient injury, establishes direction from Corporate Risk Management in the appropriate action for defense strategy.
Receives information (verbally or formally on the HPR) from facility staff regarding patient events which may lead to a claim.
Responsibility II: Risk Reduction
Networks with department directors to implement system changes aimed at optimally reducing or eliminating causative factors.
Networks with medical staff to ensure active involvement and participation in:
Risk identification
Risk analysis
Risk reduction/loss prevention problem solving and program development designed to benefit the clinical aspects of patient care and safety.
Networks with medical staff to ensure the credentialing and privilege delineating process requires information regarding professional liability experience, results of peer review activities, changes in medical staff memberships, clinical privileges, licensure, etc.
Interfaces with the Patient Advocate specific to patient complaints and assesses/recommends action, on those, which may be a source of potential litigation.
In conjunction with hospital administration recommends actions, when possible, to resolve with patient and/or family any grievances against hospital perceived as potential liability claims.
Refers policies that present particular risk in relation to previously identified problems to Corporate Risk Management.
Identifies particular practices having legal connotations to target planning of preventive and corrective measures.
Assesses liability and probability of legal action.
Is available to resolve treatment issues, including patient refusal of treatment, consent issues, HIPAA violations, AMA's, etc. under direct supervision of CEO, Corporate Legal Counsel, and Corporate Risk Management.
Responsibility III: Performance Improvement
Ensure the hospital meets Joint Commission, CMS, and state regulatory requirements.
Develop and implement a Performance Improvement Plan, evaluate the results monthly and report the results to PI Committee, MEC and BOG.
Ensure that all deficiencies identified through the Performance Improvement analysis are addressed with appropriate problem‑solving actions.
Analyze statistical data of the hospital to determine and respond to trends.
Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, CMS, TDSHS, OSHA regulations and all other applicable federal, state or local law/regulations governing health‑care entities.
Responsibility IV: Claims Management
Assists CEO in facilitating the processing of summons and complaints served on the hospital and its employees.
Reports receipt of summons and complaints immediately to Corporate Risk Management and Insurance Department.
Assists the Corporate Risk Management as needed to intervene, document and assist in the investigation of all claims.
Coordinates investigation of claims within the facility:
Directs in‑house claims investigation.
Preserves all pertinent information (medical record, x-rays, equipment, lab/pathology specimens, relevant reports/ policies and procedures).
Facilitates early reporting.
Establishes early control of situation.
Assists in obtaining materials for attorneys.
Maintains all legal case files and ensures maximum protection and discoverability.
Coordinates with and assists attorneys as they interface with the facility and employees.
Advises Business Office of actions consistent with directions from Corporate Office for unpaid accounts involved in litigation.
Responsibility V: Compliance Program
Conducts/facilitates in‑services to educate employees and physicians.
Participates in developing/reviewing policies and procedures.
Operates to maintain and facilitate systems ensuring hospital and employee adherence to UHS Compliance Program.
Responsibility VI: Committee Participation
Performance Improvement
Patient Safety Council
Peer Review
Environment of Care/Safety
Medical Staff Committee
Utilization Review
Credentials
Pharmacy & Therapeutics
Infection Control
Board of Governors
Other Committees/Meetings as necessary
Responsibility VII: Employee/Physician Education
Facilitates, develops, and provides educational programs to ensure all employees and medical staff are aware of the Risk Management/PI/Compliance concepts and its relation to their specific duties/job role in identifying and reducing liability exposures.
Plans and presents risk management/performance improvement and compliance information to all new employees at hospital orientation.
Plans and presents risk management/performance improvement and compliance information to all employees at annual update.
Plans, presents, facilitates, and/or recommends in‑services to all departments as necessary to address risk management/performance improvement and compliance problems.
Submits articles to hospital, nursing, medical staff newsletters, as appropriate.
Plans and presents in‑services/information at Department Managers meetings. Provides Risk Manager presentation specific to management levels at least annually.
Shares current literature and articles of relevance with all appropriate departments.
Plans, facilitates, presents information and suggests topics on risk management/performance improvement and compliance to Committees or hospital departments as necessary and based upon occurrences or claim patterns.
Responsibility VIII: Reporting, Report Preparation and Submission
Provides aggregate analysis of risk and performance improvement data and trend analysis of incidents to:
Administration
Corporate Risk Management
Patient Safety Council
MEC
Performance Improvement
Environment of Care/Safety Committee (Safety related only)
Governing Board
Other Committees/Department as necessary and related to the department
Incidents with Potential Claims:
Directly reports to Administration those incidents with claims potential.
Reports to Corporate RM any serious risk event involving actual or potential injury to patients and visitors; enters PCR’s (Level III/IV incidents) into STARS Database within 10 business days of the incident.
Responsibility IX: Medical Staff
Advises the Medical Director and Medical Executive Committee as needed.
Serves as a resource to the Medical Staff Credentialing Process and the Credentials Committee as needed. Data from physician peer review and risk management activities are utilized in the decision making process of granting privileges to and reappointment of medical and allied health staff.
Develops, coordinates, presents/facilitates educational programs specific to medical staff concerns.
Advise physicians on issues of interest or concern including Informed Consent process, Documentation and communication; Accountability; Response to patient/family complaints; and internal problem solving.
Provides methods to communicate patient events to the Facility Risk Manager that may result in a claim.
Responsibility X: Professional Growth and Development
Consults with Medical Director as necessary.
Regularly reviews current literature pertinent to Risk Management and Regulatory Agency Requirements.
Attends appropriate management and risk management seminars.
Consults with Corporate Risk Management as necessary.
Responsibility XI: Guest Relations
Demonstrates tact, diplomacy, and sensitivity in communications.
Is clear and accurate in communication.
Responds promptly to requests, problems, and questions.
Maintains confidentiality as appropriate.
Interacts well with co‑workers, inter and intra departments.
Note:
The essential job functions of this position are not limited to the duties listed above.
Knowledge, Skills, and Abilities
Knowledge of Joint Commission, CMS, TDSHS and all federal and state laws/regulations.
Knowledge of quality management principles, practices and techniques.
Knowledge of performance improvement planning techniques and goals.
Knowledge of computers and various software.
Strong analytical interpretation skills.
Skill in organizing and prioritizing workloads to meet deadlines.
Skill in telephone etiquette and paging procedures.
Effective oral and written communication skills.
Ability to communicate effectively with patients and co‑workers.
Ability to adhere to safety policies and procedures.
Ability to use good judgment and to maintain confidentiality of information.
Ability to work as a team player.
Ability to demonstrate tact, resourcefulness, patience and dedication.
Ability to accept direction and adhere to policies and procedures.
Ability to recognize the importance of adapting to the various patient age groups (child, adolescent, adult and geriatric).
Ability to work in a fast‑paced environment.
Ability to meet corporate deadlines.
Ability to react calmly and effectively in emergency situations.
Ability to supervise personnel.
Physical, Mental, and Special Demands
Ability to work at least 40 hours per week, and flexible hours and overtime as required.
Ability to sit for long periods, up to 8 hours.
Ability to use both hands in fine and gross manipulation of small tools (copier, computer, telephone, calculator, facsimile machine).
Ability to push and pull up to 10 lbs.
Ability to communicate clearly and see well enough to read handwritten and typewritten material.
Ability to lift and carry up to 25 lbs. dead weight.
Ability to stop and bend daily.
Ability to reach, turn, and twist above and below the waist daily.
Ability to stand and walk the facility daily.
Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical for business office atmosphere.
Ability to handle a variety of repetitive tasks at a moderate level.
Prepared to occasionally handle electrical, mechanical, or equipment emergencies.
Machines, Tools, Equipment, and Other Work Aides
Computer system and printer.
Calculator/10‑key
Telephone and paging system.
Copy machine.
Fax.
#J-18808-Ljbffr