Quality and Risk Director

Job Description

Job Description

Description: Working at Cibola General Hospital makes a big difference in our community!
Cibola General Hospital Rooted in Grants, NM - Your Community Hospital

Since opening our doors in 1959, Cibola General Hospital has been dedicated to meeting the healthcare needs of our region. As a critical access hospital in Grants, NM, we play an essential role in delivering care to surrounding rural communities, providing access to important medical services closer to home.

Many of our team members grew up right here in Cibola County. They understand the people we serve because they are part of this community, bringing a level of connection and compassion that shapes every patient experience.

Our Mission, Values, & Vision

At Cibola General Hospital , our mission is built on four guiding principles that shape every interaction and every decision we make:

• Compassion: Treating every patient with kindness, empathy, and understanding
• Accountability: Taking responsibility for delivering safe, thoughtful care
• Respect: Honoring the dignity and individuality of every person
• Excellence: Striving to provide high-quality care through continuous improvement

These values reflect our commitment to creating a healthcare experience that is personal, accessible, and meaningful for our entire community. Let our family CARE for your family.

Check Out CGH’s Excellent Benefits - Part of Your Total Rewards Package in this Role!

Benefits

Upon enrolling in our medical plan, employees and their household dependents gain the privilege of accessing any of our services at any of our facilities without the need for a co-pay. Additionally, enjoy a zero co-pay fee for all generic medications, ensuring comprehensive and affordable healthcare for your family. 

Key Benefits :

· Medical and Dental benefits, as well as voluntary Vision benefits.

· 403b Retirement Plan with employer match up to 3.5% vested at 2 years, and Roth IRA.

· Basic Life/ADD/FSA tax saving accounts for health and dependent care.

· Employee Assistance Program (EAP), voluntary long-term disability coverage.

· PTO (max rollover of 520 hours, new hires will access their PTO at 60 days), NM Sick leave.

· Holidays (6 days/year).

Housing Assistance & Fuel Stipend

For employees residing more than 65 miles from our facility, we offer an exciting choice between a fuel stipend or temporary housing, subject to availability. 

Sign-on Bonus

$15,000

Relocation Bonus

Up to $5,000 

Clinical Ladder Program

RN I to RN IV (each tier has its own wage scale)

New Grads Welcome

Starting at $36 an hour

Upon completion of 12 months will automatically increase to $40

Retention Bonuses

CGH offers retention bonuses of up to $3,500. These bonuses will be awarded every five years, starting from your fifth year as a full-time employee.

Tuition Reimbursement

Up to $5,250 per calendar year for approved programs

Up to $10,000 for master's degree or higher in leadership roles

Certification Training Program

We are thrilled to announce that we will reimburse employees for approved and job-specific certifications, including ACLS, PALS, and EMT, for example, and will also be compensated for each certification obtained, which will be an additional $0.75 to your hourly rate for each one. This initiative is designed to support your professional growth and enhance your expertise in the field. 

Employee Referral Plan

CGH rewards up to $2,000 to employees of the hospital and clinic who identify and refer potential applicantswho are hired into approved positions. The referral incentive will be awarded only for applicants who are hired and successfully complete ninety (90) days of active employment in a regular full-time position in the followingjobs: Registered Nurse, Medical Technologist / Medical Laboratory Technologist, Ultrasound Technologist,Radiologic Technologist, Pharmacist, Certified Registered Nurse Anesthetist, Physician, Physician’s Assistant, andNurse Practitioner.

Job Summary

The Quality & Risk Management Director supports the hospital’s quality improvement, patient safety, regulatory compliance, accreditation readiness, and risk management programs. This position serves as an operational and administrative extension of the Vice President of Regulatory Risk & Professional Practice Development and assists with day-to-day coordination of quality, patient safety, survey readiness, and regulatory activities across the organization.

The coordinator works collaboratively with nursing leadership, medical staff, department directors, and operational teams to promote continuous survey readiness, performance improvement, patient safety, and organizational compliance with CMS, Critical Access Hospital (CAH), and accreditation standards.

This role is designed to provide operational support for quality and risk initiatives while allowing executive leadership to focus on physician relations, strategic initiatives, regulatory oversight, and organizational operations.

Quality Improvement & Performance Improvement

• Coordinate and support hospital-wide Quality Assurance and Performance Improvement (QAPI) activities.
• Assist departments with performance improvement initiatives, corrective action plans, and follow-up monitoring.
• Track organizational quality metrics, dashboards, and regulatory indicators.
• Assist with collection, validation, trending, and reporting of quality and patient safety data.
• Support implementation and monitoring of process improvement initiatives.
• Maintain action plan trackers and ensure accountability for assigned deliverables.

Risk Management & Patient Safety

• Coordinate the hospital’s incident reporting and event management processes.
• Review occurrence reports and escalate high-risk concerns to leadership.
• Assist with preliminary investigations of adverse events, near misses, grievances, and patient safety concerns.
• Coordinate follow-up documentation and maintain risk management logs and tracking systems.
• Assist with Root Cause Analyses (RCA), focused reviews, and risk mitigation activities.
• Monitor trends and identify opportunities for operational and clinical risk reduction.

Regulatory & Accreditation Readiness

• Assist with ongoing readiness for CMS, The Joint Commission, Critical Access Hospital Conditions of Participation, and state regulatory requirements.
• Coordinate survey readiness activities including tracers, mock surveys, rounding, and compliance audits.
• Assist with maintaining regulatory documentation, evidence binders, and accreditation readiness materials.
• Track regulatory findings, corrective action plans, and sustainability monitoring.
• Support policy review and revision processes to ensure regulatory alignment.

Administrative & Operational Support

• Prepare agendas, reports, dashboards, committee minutes, and executive summaries for quality, safety, and regulatory meetings.
• Coordinate meeting follow-up items and maintain tracking tools for organizational initiatives.
• Assist with peer review tracking, FPPE/OPPE administrative support, and provider quality documentation.
• Maintain confidential quality and risk management files in accordance with regulatory and legal requirements.
• Support special projects and organizational initiatives assigned by executive leadership.

Education & Collaboration

• Assist with staff education related to patient safety, event reporting, regulatory compliance, and quality improvement.
• Collaborate with department leaders to improve compliance, documentation, and operational workflows.
• Promote a culture of safety, accountability, and continuous improvement across the organization.
• Serve as a resource to departments regarding quality and risk management processes.

Requirements:

Required Qualifications

• Bachelor’s degree required.
• Current Registered Nurse (RN) license required.
• Minimum of three (3) years of healthcare experience required.
• Experience in quality improvement, accreditation, compliance, patient safety, or risk management preferred.
• Critical Access Hospital or rural healthcare experience preferred.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) preferred.
• Experience with CMS Conditions of Participation, The Joint Commission, or Critical Access Hospital standards preferred.
• Certification in Healthcare Quality (CPHQ), Patient Safety (CPPS), or Healthcare Risk Management (CPHRM) preferred.
• Experience with incident reporting systems, regulatory surveys, and performance improvement methodologies preferred.

Knowledge, Skills, and Abilities

• Knowledge of hospital regulatory and accreditation standards.
• Strong organizational and project coordination skills.
• Ability to manage multiple priorities and deadlines simultaneously.
• Strong analytical and critical thinking skills.
• Excellent written and verbal communication abilities.
• Ability to maintain confidentiality and exercise professional judgment.
• Proficiency with Microsoft Office applications and healthcare reporting systems.
• Ability to work collaboratively across departments and leadership levels.

Physical Requirements

• Prolonged periods of sitting, standing, and computer work.
• Ability to travel throughout hospital departments.
• Ability to occasionally lift up to 25 pounds.

Work Environment

This position operates in both clinical and administrative healthcare settings and requires interaction with leadership, providers, staff, patients, and regulatory agencies as needed. The role involves handling confidential and sensitive information and supporting time-sensitive organizational priorities.

Inclusivity and Reasonable Accommodation:

Cibola General Hospital is an Equal Opportunity Employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status. Note that a criminal background check will be conducted periodically as a condition of ongoing employment. CGH will reasonably accommodate qualified individuals with a disability so that they can perform the essential functions of a job unless doing so causes a direct threat to these individuals or others in the workplace and the threat cannot be eliminated by reasonable accommodation, or if the accommodation creates an undue hardship for CGH. We also seek to provide reasonable accommodation for the interview process.