Description:
Position Purpose: Plans, organizes, directs and manages patient safety/risk management; quality assurance/performance improvement; medical staff/medical education; professional/general liability coverages via self-insurance trust as well as all other insurance; manages litigation and claims activities in conjunction with counsel and third party claims administrators; operation of the Corporate Responsibility Program (CRP) for CHP; general legal services including contract review and drafting/preparing corporate documents and general legal support.Essential Functions:
- Overall responsibility for claims and litigation administration of the various self- insurance trusts as well as commercial insurance for CHP in order to protect the assets of the organization. 30%
- Oversee hospital-wide performance improvement and quality assurance initiatives including compliance with JCAHO standards to maintain JCAHO accreditation. Compile, review and submit data on various initiatives to entities such as Ascension Health on adverse drug events, IHI, CMS, IHA and Care Science. 25%
- Maintain effectiveness of the Corporate Responsibility Program including insuring compliance with legal and regulatory requirements such as HIPAA, Stark Self-Referral Law, Anti-Kickback Statute, Hospital Licensing Act, Medicare Conditions of Participation and JCAHO. Serve as Corporate Responsibility Officer reporting to Chief Executive Officer and Board or Board designated committee such as the Audit Committee. 15%
- Maintain and trend risk management data, manage and respond to adverse events, direct patient safety programs to ensure quality, safe patient care and compliance with JCAHO patient safety goals and other patient safety initiatives. Serve as Patient Safety Officer. 10%
- Provide general legal services including contract review, drafting/preparing legal documents, general legal advice, serve as Registered Agent for all affiliated corporations, review legal aspects of administrative policies. 10%
- Administer contracts and affiliation agreements with hospital based physicians and medical schools, oversee credentialing and privileging activities by medical staff office, ensure compliance/updates of Medical Staff Bylaws and Rules and Regulations, assist in resolution of issues involving medical staff members, residents and medical students. 10%
General Job Requirements:
- 8 - 10 years legal experience with at least 5 plus years in a health care organization required.
- 5 years clinical experience as Registered Nurse or in another health care profession preferred.
- Excellent legal, analytical and interpersonal skills.
