Quality Management/Risk Management Director

POSITION SUMMARY

The Quality and Risk Management Director is responsible for leading, developing, and implementing comprehensive quality improvement, patient safety, and risk management programs within the Tribal clinic. This role ensures that clinical and operational practices align with regulatory standards, accreditation requirements, and culturally appropriate care principles that honor the Tribal community. The Director collaborates with leadership, providers, and staff to promote a culture of continuous improvement, patient safety, and accountability. They oversee performance improvement initiatives, incident reporting systems, compliance activities, and risk mitigation strategies to enhance patient outcomes and organizational effectiveness. This position also plays a critical role in integrating culturally responsive care into quality frameworks, supporting health equity, and ensuring services reflect the values, traditions, and needs of the Tribal population served.

ESSENTIAL FUNCTIONS

Quality Management Director 1.Demonstrates effectiveness in planning and implementing the Quality Program to meet the needs of the Laguna Healthcare Corporation (LHC). 2.Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment, and services by assisting to implement standard work. 3.Demonstrates effective organizational skills through ongoing interaction with chief medical officer (CMO), director of nursing (DON), ancillary department managers, administrative team, and Governing Body to facilitate the facility wide Performance Improvement program. 4.Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes. 5.Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by federal, state, and Tribal healthcare regulations. 6.Oversees preparation for review by regulatory agencies including AAAHC, educates, and assists department supervisors to maintain appropriate policies and procedures to fulfill requirements and regulations. 7.Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team. Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workload. 8.Actively participates in QM meetings, provides oversight for meeting preparation, gives presentations on performance improvement to committee members. 9.Develops Quality Plan in collaboration with the QM Committee. Prepares quarterly and annual evaluation of PI program, presents this to QM Committee and Governing Body. Develops PI annual work plan, monitors work plan to evaluate time frame compliance. 10.Ensures, directs submission of monthly, quarterly, and annual reports as required. 11.Develops, in collaboration with the CMO, clinical care guidelines for LHC, in addition to, process and system guidelines. 12.Exercise, sound judgment and decision-making skills. Demonstrates the ability to formulate quality action plans, perform root cause analysis and recommend alternative courses of action to reduce potential quality and/or risk concerns or to improve existing processes.

ESSENTIAL FUNCTIONS RISK MANAGEMENT DIRECTOR

1.Leads and oversees risk management processes, including the identification of potentially compensable events, risk investigations, incident reporting, and claims management. 2.Conducts medical record review to identify actual or potential risks and ensures high standards of documentation practices. 3.Develops and presents comprehensive risk identification and grievance reports to clinic administration, the medical staff, and the Governing Body to support informed decision-making. 4.Refers information gathered from risk identification reporting to the appropriate department manager/administrative staff member and clinic mechanism for analysis and corrective action to eliminate or reduce risk. Leads and promotes patient safety. 5.Leads and mentor's others in root cause analysis (RCA), healthcare failure mode and effects analysis (FMEA) and hazard vulnerability analysis (HVA) teams. 6.Summarizes risk management and patient safety data for appropriate evaluation and risk trend analysis. 7.Advises clinical staff regarding patient care to ensure patient's needs are met and clinic policy is followed. 8.Champions the implementation and continuous improvement of current documentation practices within the risk management and patient safety arena. 9.Provides education to medical staff on risk management and patient safety practices including, but not limited to, risk identification reports, quality notification reports, key elements of risk reduction, orientation to legal issues and education regarding proper documentation practices that present potential liability problems. 10.Assists in development of policies and procedures related to risk management practices. 11.Reviews, evaluates, and recommends action on risk related matters pertaining to patients, visitors, staff, students, physical plant, and personal property.

OTHER RESPONSIBILITIES

In terms of the performance of their respective tasks and duties, an employee of Laguna Healthcare Corporation is expected to conform to the following: 1.Uphold all principles of confidentiality and patient care to the fullest extent. 2.Adhere to all professional and ethical behavior standards of the healthcare industry. 3.Maintain all licensures and certifications required of position. 4.Interact in an honest, trustworthy, and respectful manner with patients, employees, visitors, and vendors. 5.Participate in Board of Director meetings, departmental staff meetings, quality management activities, and educational programs as required. 6.Comply with Laguna Healthcare Corporation policies and procedures.

MINIMUM MANDATORY QUALIFICATIONS

Experience:

1.Three (3) years clinical experience in an acute care or ambulatory setting. 2.Three (3) years experience in Quality Management. 3.Two (2) years experience in Risk Management.

Education:

1.Bachelor of Nursing degree, Master's degree preferred. 2.CPHQ certification preferable

License/Certification:

Registered Nurse Mandatory Knowledge, Skills, Abilities and Other Qualifications:

1.Excellent verbal and written communication skills. 2.Strong time management and organizational skills. 3.Self-driven and motivated to increase efficiency and performance. 4.Ability to develop and maintain recordkeeping systems and procedures. 5.Skill in the use of personal computers, preferably in a PC, Windows-based operating environment systems such as Windows 6.Ability to communicate effectively, both orally and in writing. 7.Skill in organizing resources and establishing priorities. 8.Skill in examining and re-engineering operations and procedures, formulating policy, and developing and implementing new programs and procedures. 9.Ability to clearly communicate medical information to professional practitioners and/or the general public.

WORK ENVIRONMENT

Work environment: The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. Limited overnight travel may be required from time to time. This position may be exposed to certain health risks that are inherent when working within a health center facility, such as potential exposure to hazardous chemicals, sharps, and infectious body fluids. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical demands:

The physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk, hear, and perform repetitive motions. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors, and staff. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Operation of a motor vehicle required to travel between LHC facilities and perform other assigned off-site tasks.

Mental demands:

There are a number of deadlines associated with this position. The employee must be able to manage frequent interruptions and must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

TRIBAL PREFERENCE LHC

will apply "Indian Preference" as an employment criterion and not a "racial classification." The Laguna Healthcare Corporation has implemented a Tribal Preference in Employment Policy. Pursuant to this Policy, applicants who possess the knowledge, skills, and abilities required by this position, and who are enrolled members of the Pueblo of Laguna, will be given primary preference in hiring and employment for this position. Members of other Federally recognized Indian Tribes will be given secondary preference for hiring and employment after providing proof of Tribal membership.

OTHER Confidentiality:

All employees must uphold all principles of confidentiality to the fullest extent. This position will have access to sensitive information, and a breach of these principles will be grounds for immediate termination.

Background Investigation:

This position may be subject to a criminal history background check, a suitability background check, and/or a credit report check. In addition, some positions are subject to a more extensive background check to ensure compliance with Public Law 101-630 Indian Child Protection and Family Violence Prevention Act. Candidates must be able to successfully pass all required background checks to qualify for this position.

Drug Screening:

All applicants must successfully pass a pre-employment drug screening prior to beginning employment and will be subject to random drug testing.

Disclaimer:

The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.: Quality Management/Risk Management Director 6 Basswood Road, Paraje, NM 87007 POSITION SUMMARY The Quality and Risk Management Director is responsible for leading, developing, and implementing comprehensive quality improvement, patient safety, and risk management programs within the Tribal clinic. This role ensures that clinical and operational practices align with regulatory standards, accreditation requirements, and culturally appropriate care principles that honor the Tribal community. The Director collaborates with leadership, providers, and staff to promote a culture of continuous improvement, patient safety, and accountability. They oversee performance improvement initiatives, incident reporting systems, compliance activities, and risk mitigation strategies to enhance patient outcomes and organizational effectiveness. This position also plays a critical role in integrating culturally responsive care into quality frameworks, supporting health equity, and ensuring services reflect the values, traditions, and needs of the Tribal population served.

ESSENTIAL FUNCTIONS

Quality Management Director 1.Demonstrates effectiveness in planning and implementing the Quality Program to meet the needs of the Laguna Healthcare Corporation (LHC). 2.Develops and coordinates processes to monitor quality of care. Identifies opportunities to improve patient care, treatment, and services by assisting to implement standard work. 3.Demonstrates effective organizational skills through ongoing interaction with chief medical officer (CMO), director of nursing (DON), ancillary department managers, administrative team, and Governing Body to facilitate the facility wide Performance Improvement program. 4.Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes. 5.Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by federal, state, and Tribal healthcare regulations. 6.Oversees preparation for review by regulatory agencies including AAAHC, educates, and assists department supervisors to maintain appropriate policies and procedures to fulfill requirements and regulations. 7.Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team. Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workload. 8.Actively participates in QM meetings, provides oversight for meeting preparation, gives presentations on performance improvement to committee members. 9.Develops Quality Plan in collaboration with the QM Committee. Prepares quarterly and annual evaluation of PI program, presents this to QM Committee and Governing Body. Develops PI annual work plan, monitors work plan to evaluate time frame compliance. 10.Ensures, directs submission of monthly, quarterly, and annual reports as required. 11.Develops, in collaboration with the CMO, clinical care guidelines for LHC, in addition to, process and system guidelines. 12.Exercise, sound judgment and decision-making skills. Demonstrates the ability to formulate quality action plans, perform root cause analysis and recommend alternative courses of action to reduce potential quality and/or risk concerns or to improve existing processes.

ESSENTIAL FUNCTIONS RISK MANAGEMENT DIRECTOR

1.Leads and oversees risk management processes, including the identification of potentially compensable events, risk investigations, incident reporting, and claims management. 2.Conducts medical record review to identify actual or potential risks and ensures high standards of documentation practices. 3.Develops and presents comprehensive risk identification and grievance reports to clinic administration, the medical staff, and the Governing Body to support informed decision-making. 4.Refers information gathered from risk identification reporting to the appropriate department manager/administrative staff member and clinic mechanism for analysis and corrective action to eliminate or reduce risk. Leads and promotes patient safety. 5.Leads and mentor's others in root cause analysis (RCA), healthcare failure mode and effects analysis (FMEA) and hazard vulnerability analysis (HVA) teams. 6.Summarizes risk management and patient safety data for appropriate evaluation and risk trend analysis. 7.Advises clinical staff regarding patient care to ensure patient's needs are met and clinic policy is followed. 8.Champions the implementation and continuous improvement of current documentation practices within the risk management and patient safety arena. 9.Provides education to medical staff on risk management and patient safety practices including, but not limited to, risk identification reports, quality notification reports, key elements of risk reduction, orientation to legal issues and education regarding proper documentation practices that present potential liability problems. 10.Assists in development of policies and procedures related to risk management practices. 11.Reviews, evaluates, and recommends action on risk related matters pertaining to patients, visitors, staff, students, physical plant, and personal property.

OTHER RESPONSIBILITIES

In terms of the performance of their respective tasks and duties, an employee of Laguna Healthcare Corporation is expected to conform to the following: 1.Uphold all principles of confidentiality and patient care to the fullest extent. 2.Adhere to all professional and ethical behavior standards of the healthcare industry. 3.Maintain all licensures and certifications required of position. 4.Interact in an honest, trustworthy, and respectful manner with patients, employees, visitors, and vendors. 5.Participate in Board of Director meetings, departmental staff meetings, quality management activities, and educational programs as required. 6.Comply with Laguna Healthcare Corporation policies and procedures.

MINIMUM MANDATORY QUALIFICATIONS

Experience:

1.Three (3) years clinical experience in an acute care or ambulatory setting. 2.Three (3) years experience in Quality Management. 3.Two (2) years experience in Risk Management.

Education:

1.Bachelor of Nursing degree, Master's degree preferred. 2.CPHQ certification preferable

License/Certification:

Registered Nurse Mandatory Knowledge, Skills, Abilities and Other Qualifications:

1.Excellent verbal and written communication skills. 2.Strong time management and organizational skills. 3.Self-driven and motivated to increase efficiency and performance. 4.Ability to develop and maintain recordkeeping systems and procedures. 5.Skill in the use of personal computers, preferably in a PC, Windows-based operating environment systems such as Windows 6.Ability to communicate effectively, both orally and in writing. 7.Skill in organizing resources and establishing priorities. 8.Skill in examining and re-engineering operations and procedures, formulating policy, and developing and implementing new programs and procedures. 9.Ability to clearly communicate medical information to professional practitioners and/or the general public.

WORK ENVIRONMENT

Work environment: The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. Limited overnight travel may be required from time to time. This position may be exposed to certain health risks that are inherent when working within a health center facility, such as potential exposure to hazardous chemicals, sharps, and infectious body fluids. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical demands:

The physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk, hear, and perform repetitive motions. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors, and staff. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Operation of a motor vehicle required to travel between LHC facilities and perform other assigned off-site tasks.

Mental demands:

There are a number of deadlines associated with this position. The employee must be able to manage frequent interruptions and must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

TRIBAL PREFERENCE LHC

will apply "Indian Preference" as an employment criterion and not a "racial classification." The Laguna Healthcare Corporation has implemented a Tribal Preference in Employment Policy. Pursuant to this Policy, applicants who possess the knowledge, skills, and abilities required by this position, and who are enrolled members of the Pueblo of Laguna, will be given primary preference in hiring and employment for this position. Members of other Federally recognized Indian Tribes will be given secondary preference for hiring and employment after providing proof of Tribal membership.

OTHER Confidentiality:

All employees must uphold all principles of confidentiality to the fullest extent. This position will have access to sensitive information, and a breach of these principles will be grounds for immediate termination.

Background Investigation:

This position may be subject to a criminal history background check, a suitability background check, and/or a credit report check. In addition, some positions are subject to a more extensive background check to ensure compliance with Public Law 101-630 Indian Child Protection and Family Violence Prevention Act. Candidates must be able to successfully pass all required background checks to qualify for this position.

Drug Screening:

All applicants must successfully pass a pre-employment drug screening prior to beginning employment and will be subject to random drug testing.

Disclaimer:

The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.: