Job Description

Job Purpose and Position Overview

Provide organizational leadership, direction, coordination, and oversight of regulatory compliance, the Compliance and Ethics Program, enterprise risk management, accreditation readiness, and policy governance. Organize compliance oversight around seven core elements and risk management around eight domains: operational, clinical and patient safety, strategic, financial, human capital, legal and regulatory, technology, and hazard. Coordinate the Policy Committee and organizational policy review and approval processes. Collaborate with the Patient Safety/Quality Coordinator and department leaders to plan, implement, and evaluate safety activities, reduce risk, and align improvement with the Quality Assurance and Performance Improvement (QAPI) Program.

The manager is accountable for program coordination, organizational oversight, and escalation. Department leaders retain accountability for technical assessments, clinical practice, and implementation of corrective actions in their areas. Legal matters are coordinated with the Chief Executive Officer (CEO) and Legal Counsel through established channels.

Compliance Program Leadership

Lead the Compliance and Ethics Program through the seven core elements below. Integrate compliance across the workforce and Governing Body, promote ethical conduct and open communication, and identify and respond to fraud, waste, abuse, and other compliance concerns.

• Coordinate program leadership, committee oversight, priorities, and reporting with the Director of Quality and. Exercise delegated authority to obtain relevant records, convene reviews, and escalate unresolved concerns. Maintain direct access to the CEO and Governing Body or designated oversight committee for significant compliance matters, including concerns involving leadership or conflicts of interest. Formal Compliance Officer designation and delegated authority are established by organizational appointment.
• Provide organizational policy oversight and coordinate the Policy Committee, multidisciplinary review, and approval routing. Oversee policy development, revision, scheduled review, publication, and retirement; maintain assigned owners, templates, version control, approval records, and access to current approved policies. Coordinate code of conduct development, review, education, and implementation with Human Resources. Ensure policies align with practice, regulatory requirements, and the code of conduct; monitor review and approval deadlines, escalate overdue items, report policy performance, and support communication, education, and implementation with department leaders.
• Coordinate compliance education and support staff understanding and implementation of policy changes, reporting expectations, and lessons learned.
• Establish internal reviews and audits of clinical and nonclinical activities; analyze findings, evaluate controls, and monitor compliance and program effectiveness.
• Promote accessible reporting of concerns and communicate compliance goals, findings, and achievements to internal and external stakeholders through appropriate channels.
• Lead or coordinate investigation of intended and unintentional misconduct; ensure appropriate response, remediation, assigned owners, completion dates, and evaluation of sustained effectiveness.
• Support fair and consistent application of compliance expectations with Human Resources, leadership, and Legal Counsel. Escalate significant concerns and overdue or ineffective corrective actions through established channels.

Enterprise Risk Management

Lead an ongoing, systematic process to identify, assess, prioritize, mitigate, and monitor risks across the eight domains below. Coordinate annual organizational risk assessment and reviews triggered by events or changes. Maintain a centralized inventory of applicable requirements, risk owners, review schedules, findings, mitigation plans, and status. Department leaders retain responsibility for technical assessments and implementation of controls; the manager provides coordination, subject matter support, follow-through, and escalation.

• Partner with department leaders to assess risks in internal processes, staffing systems, credentialing workflows, documentation, communication, chain of command, and adherence to practice; support policy development, change management, and effective controls. Coordinate monitoring of CMS operating requirements, including applicable bed limits, annual average acute inpatient length of stay, and continuous emergency service availability, with Nursing, Case Management, and administration; escalate exceptions while operational accountability remains with department leaders.
• Coordinate electronic incident reporting with the Patient Safety/Quality Coordinator, including triage, assignment, investigation, trend analysis, follow-up, and timely closure; establish clear accountability and avoid duplicate work. Collaborate with the Patient Experience Specialist or Patient Advocate and the coordinator to ensure complaints and grievances receive timely escalation and resolution through the grievance program and that related safety concerns receive investigation and follow-up.
• Collaborate with the Patient Safety/Quality Coordinator and clinical leaders to plan, implement, and evaluate patient safety activities aligned with QAPI and evidence-based care. Jointly conduct quality-of-care and documentation reviews, safety rounds, tracers, and proactive process reviews addressing medication safety, falls, patient identification, communication, care transitions, infection prevention, hospital-acquired conditions, suicide, self-harm, and applicable ligature or environmental risks. Coordinate patient protection compliance with responsible leaders, including patient rights, informed decisions and consent, advance directives, abuse prevention, and restraint/seclusion safeguards.
• Coordinate investigations, multidisciplinary event reviews, and root cause analyses with the Patient Safety/Quality Coordinator, using data analysis, chart review, and staff interviews. Together with responsible leaders, ensure prompt escalation and protective action for serious events and near misses, develop corrective plans with owners, deadlines, and effectiveness measures, evaluate sustained improvement, and escalate overdue or ineffective actions. Collaborate on safety culture assessment, staff education, safety alerts, lessons learned, and improvement monitoring. Coordinate identification, timely submission, and documentation of applicable mandatory external reports, including abuse concerns and reportable restraint/seclusion deaths, with designated leaders and Legal Counsel.
• Advise leadership on risks associated with organizational priorities, new or changing services, partnerships, affiliations, contracts, conflicts of interest, reputation, and changing community or regulatory expectations. Coordinate multidisciplinary review and mitigation planning to support informed decisions and sustainable change.
• Collaborate with Finance, revenue cycle leaders, executive leadership, and Legal Counsel to assess exposures involving claims, malpractice, litigation, insurance, billing and collection, fraud, waste, abuse, and business interruption. Evaluate controls and escalate material exposures while financial management remains with designated leaders.
• Partner with Human Resources, Employee Health, Medical Staff leadership, and department leaders to assess staffing, competency, credentialing and privileging, recruitment and retention, turnover, absenteeism, fatigue, workplace injury, workers’ compensation, and workplace violence risks. Support investigations, preventive controls, education, and corrective action within established responsibilities.
• Coordinate CMS certification, applicable Hospital and other entity Conditions of Participation, accreditation, and continuous survey readiness with the Director of Quality. Monitor regulatory changes, communicate affected requirements, coordinate survey responses and plans of correction, and verify sustained compliance. Oversee compliance review and tracking of required agreements and contracted services, including applicable network, transfer, transportation, credentialing/quality assurance, and telemedicine arrangements; confirm accountable owners and integration of contracted service performance into QAPI.
• Coordinate tort claims, disclosures, administrative investigations, boards, issue briefs, state licensure board reporting, and other legal, liability, and contractual matters with authorized leaders and Legal Counsel. Prepare draft responses to Tribal, State, and Federal Courts and outside agencies for CEO review in coordination with Legal Counsel.
• Partner with Information Technology, Clinical Informatics, privacy and security personnel, and equipment owners to assess electronic health record, privacy, cybersecurity, clinical technology, medical device, data integrity, availability, and downtime risks. Coordinate assessment tracking, incident review, and mitigation follow-through while technical controls remain with responsible departments. Coordinate privacy concerns and breach evaluation with the designated Privacy and Security Officers; formal officer responsibilities remain with appointed individuals unless separately assigned to this position.
• Partner with Environment of Care, Facilities, Safety, Security, Infection Control, and Emergency Preparedness to oversee risk assessment coordination for safety, security, hazardous materials and waste, fire and life safety, equipment, utilities, construction and renovation, construction infection control, natural and property hazards, facility and community hazards, and continuity of essential services. Monitor mitigation and escalate overdue assessments and unresolved risks.

Integrated Performance Monitoring and Reporting

• Maintain a compliance and risk dashboard coordinated with the Patient Safety/Quality Coordinator and quality reporting to evaluate program effectiveness and efficiency, risk trends, policy performance, audit and investigation findings, assessment completion, event review, and corrective action outcomes.
• Ensure findings, program activities, and improvement results are accurately analyzed, documented, tracked, and reported. Communicate significant risks, overdue actions, and ineffective controls to the Director of Quality and appropriate oversight committees.
• Report Compliance and Risk Management Program activities and performance to the Quality Management Committee and Governing Body through established channels. Integrate findings with QAPI while maintaining clear responsibility for compliance, risk management, and quality improvement activities.
• Perform other duties as assigned.

Required Qualifications and Skills

• Bachelor’s degree required; master’s degree preferred. A health-related degree and hospital risk management or compliance experience are preferred. Minimum of two years of experience in risk management and compliance. Certified Professional in Health Care Risk Management (CPHRM) certification preferred.
• Broad functional knowledge of healthcare laws, regulations, and accreditation requirements, including applicable CMS Conditions of Participation, EMTALA, the Privacy Act, HIPAA, and Joint Commission standards.
• Thorough working knowledge of CMS requirements, QAPI, and case management, with working knowledge of patient safety, infection prevention and control, emergency preparedness, and Environment of Care requirements.
• Ability to lead compliance program elements, coordinate assessment across the eight enterprise risk domains, oversee organizational policy management and Policy Committee processes, and collaborate with the Patient Safety/Quality Coordinator and department leaders while maintaining clear accountability.
• Knowledge of event investigation, root cause analysis, proactive risk evaluation, corrective action development, and evaluation of sustained improvement.
• Ability to identify and prioritize problems, establish evaluation criteria, select and implement data collection methods, interpret statistical findings, recommend and implement improvements, and maintain accurate documentation and records.
• Strong computer skills to extract, compile, enter, analyze, and present data using organizational systems, including Electronic Health Record, data repository, Excel, Word, PowerPoint, electronic incident reporting, and policy management systems.
• Excellent verbal and written communication, staff education, multidisciplinary facilitation, and presentation skills for large and small audiences. Strong organization, confidentiality, interpersonal judgment, and ability to manage competing priorities with minimal supervision.

Physical Cognitive and Language Requirements

• Ability to lift up to 10 pounds; walk, stand, and sit for extended periods; and use hands to operate a computer keyboard, telephone, and other office equipment. Ability to read, write, calculate, reason, analyze, and solve problems; demonstrate strong interpersonal and social interaction skills; and work with minimal to no supervision. Ability to read, write, and speak English fluently and consistently communicate professionally and effectively.

Certificates Licenses and Registrations

• Certified Professional in Health Care Risk Management (CPHRM) certification preferred.
• All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.

WCHS is an equal opportunity employer.

All applicants must comply with 45 CFR 1301, Subpart D, Section 1301.31 C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and comply with PL 101-630 and PL 101-637 regarding criminal records check. As provided by Federal Law, all qualified Native American and Veteran applicants shall receive preference over Non-Native American applicants. In the absence of qualified Native American applicants, consideration will be given to all other applicants without regard to race, color, religion, gender, gender orientation/identity, national origin, age, marital status, veteran status, genetic information, disability or any other reason prohibited by law in provision of employment opportunities and benefits. WCHS participates in E-Verify.