Director, Risk Management & Performance Improvement

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Director, Risk Management & Performance Improvement

Corporate, Admin, Mgt. Full Time TLR- Smithville- IP, Smithville, TX, US

The Last Resort Recovery Center offers a comprehensive range of treatment options designed to meet the diverse needs of men and their families struggling with many different types of substances. From personalized therapy sessions that integrate evidence-based practices like Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) to holistic approaches that emphasize mindfulness, nutrition, and physical wellness, our programs are designed to support clients every step of the way. The Last Resort offers a unique and powerful approach to addiction recovery through our Equine Therapy program. Nestled in the serene outskirts of Austin on our 55-acre ranch, our campus provides men with the opportunity to heal and grow from drug and alcohol abuse.

We are seeking a Director of Risk Management & Performance Improvement to add to our team. This individual will oversee the planning, organizing, directing and control all aspects of risk management activities. They will ensure a safe environment for the protection of patients, clients, employees and visitors to the facility in such a manner as to comply with laws, regulations and the standards of the accrediting and approval agencies.

Responsibilities

• Investigate and analyze actual and potential risks in the facility; assess liability and probability of legal action for potential notification
• Implement, educate and encourage incident reporting system throughout the facility
• Implement risk management program throughout the facility
• Develop and implement infrastructures and systems that support patient safety
• Work closely with Clinical Department practice to ensure the organization's procedures and policies are being followed by all employees
• Work with internal auditors, security contractors, and other staff to establish an internal control system
• Monitor and analyze program performance data to determine program effectiveness and identify opportunities for improvement
• Ensure compliance with all administrative requirements
• Responsible for identifying high-risk areas that could cause harm to people receiving services, visitors, and employees
• Maintain database of full disclosure activities and provide oversight for review programs and provide technical support as needed
• Provide staff management to include hiring, development, training, performance management and communication to ensure effective and efficient department operation
• Serve as a resource and consultant for risk management activities, performance improvement, policy/procedure development and compliance initiatives
• Collaborate with clinical staff and management for prevention of clinical risks throughout the facility.
• Develop effective working relationships with clinical staff and administrative personnel to facilitate the delivery of patient care
• Create and implement policies and procedures that improve both patient care and employee safety. Ensure the application of institutional policies, especially those regarding patient rights, confidentiality and full disclosure
• Develop, implement, coordinate and facilitate the Quality Assurance/Process Improvement (QAPI) Program for facility
• Assess QAPI needs and trends for the facility program by reviewing current practices and gathering, compiling and evaluating data related to employees, services, and patient feedback
• Delegate and support the QAPI and risk management activities of Department Directors to ensure desired, department-related outcomes for patient care and safety
• Monitors and maintains compliance for accreditation for the facility
• Monitors and maintains compliance for state licensure for the facility

Qualifications

• Bachelor’s degree, risk management, business or a related field required
• Five or more years’ experience in risk management position
• One or more years’ supervisory experience required
• Demonstrated knowledge of laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of accrediting agencies as applicable to the facility preferred
• Comfortable working with the public
• If recovering, two (2) years of continuous, verifiable sobriety
• Maintain appropriate professional boundaries and confidentiality, including a working knowledge of 45 CFR “Health Insurance Portability and Accountability Act” and 42 C.F.R. Part 2 “Confidentiality of Alcohol and Drug Abuse Patient Records”
• Ability to maintain composure with periodic exposure to high-risk behaviors that may result in agitation, aggression, or violence or exposure to critical incident, and possible sentinel events

Preferred Qualifications

• Master’s degree in health care management, nursing or related field preferred

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

Student Loan Repayment – Available for nurses and therapists.

Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.

Generous PTO – A robust paid time off policy to support work-life balance.

Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.