Job Description

Location: Steward Health Care
Posted Date: 2/25/2021

Directs risk management and clinical quality activities for the system, including patient care, risk management, patient safety, performance improvement and infection control. Develops strategic plans and policies for improved clinical quality. Frequent contact with system and hospital professional and/or clinical support personnel who provide patient care.

Essential Duties and Responsibilities

  • Oversee, coordinate, and serve as the primary point of contact for system wide risk management policies and activities.
  • Responsible for developing and implementing a systematic approach for managing and minimizing risk throughout the system.
  • Develop guidelines, recommendations, or implements process improvements to address high areas of vulnerability within the organization.
  • Responsible for developing a systematic approach to assessing and improving organizational processes as well as ensuring the development of appropriate policies.
  • Conduct reviews of policies, procedures, OSHA directives, etc., and guidelines to recommend changes and prioritization of performance improvement and risk management activities.
  • Responsible for high functioning QAPI programs across the system
  • Perform ongoing education to staff based on changes in the appropriate standards and requirement of hospital processes.
  • Work with peers and hospital delegates to help provide risk management training, knowledge, and skills to clinical staff and other trainees.
  • Implement, coordinate, and update the organization’s risk management program.
  • Conduct special assignments. Participate or lead organization committees, teams, etc., as a risk management expert.
  • Perform a variety of duties related to managing potential risks and liabilities. This includes creating and implementing policies that improve both patient care and employee safety.
  • Educate and training staff about potential risks.
  • In coordination with internal counsel, assists in situations of medical malpractice or risk management claims (e.g. HIPAA violations, Cyber threats, etc.).
  • Continuously assess potential risks.
  • Receive, document, and investigate patient complaints or accusations of abuse or negligence.
  • Collect and access data to identify problems or weaknesses in hospital procedures.
  • Draft and submit accident reports to the appropriate persons and agencies.
  • Ensure legal aspects of medical records practices, release of information, and company responsibility for confidentiality and privacy are being met.
  • Complete quarterly risk management assessments and an annual risk management report for Executive Leadership and key management staff.
  • Develop and implement an annual health care risk management training plan for all staff members based on identified areas/activities of highest clinical risk for the hospitals (including, but not limited, to obstetrical procedures and infection control) and any non-clinical trainings appropriate for hospital staff [including Health Insurance Portability and Accountability Act (HIPAA) medical record confidentiality requirements].
  • Manage the incident report system including tracking of incidents. Work with unit directors and department leads to resolve incidents and reporting to the insurance carriers as necessary.
  • Oversees the development, management and annual review of company policies and procedures, in collaboration with the policy committee and executive reviewers.
  • In conjunction with the Vice President of Compliance, conduct an enterprise risk assessment for the organization, with Risk Management’s focus on clinical and environment of care risk.
  • Additional duties, project and responsibilities as assigned.

Reporting Structure:

  • Reports directly to Steward Health Care System Chief Medical Officer
  • Oversees the following direct reports:
    • Director of Risk Management (East)
    • Director of Risk Management (West)
    • Director of patient system administration
    • Program Director of Infection Control (East)
    • Program Director of Infection Control (West)
    • Oversees hospital-based Risk Managers and Infection Control Specialists


  • Must be able to work in a fast-paced environment while maintaining a high degree of tact and composure in dealing with internal and external customers.
  • Demonstrated leadership abilities.
  • Excellent management, interpersonal and communication skills.
  • Ability to work collaboratively, and act persuasively in sensitive situations.
  • Strong organization and project management skills including ability to prioritize and multitask.
  • Demonstrated ability to utilize data to develop and implement strategic planning.
  • Knowledge of hospital policies and procedures, as well as governmental regulations including TJC, DNV and CMS standards and regulations.
  • Familiar and up to date with Federal Torts Claims Act (FTCA), specifically regarding risk management.
  • Ability and willingness to train staff in risk management, and incident reporting
  • Effectively with a variety of people, work as a team member, exercise good judgment, and maintain a friendly and positive attitude at all times.
  • Ability to operate independently, meet deadlines, supervise personnel, and train business unit personnel when necessary.
  • Ability to assist in enterprise wide risk assessments, present to the Executive Leadership Team, and address/mitigate risks.
  • Self-directed and require little oversight in performance of duties.
  • Requires excellent interpersonal skills, analytical and conceptual thinking ability, team building ability with an emphasis on performance and achievement.
  • Experience with the management of healthcare-related liability claims.


  • Graduate of an accredited school of nursing with minimum of 5 years clinical experience
  • Master’s degree in healthcare related field preferred. Bachelor of Science is Nursing (BSN) or bachelor’s degree in related clinical field will be considered
  • A minimum of ten (10) years’ experience in risk management or related field is required, with at least five (5) years’ experience in a medical setting level role including multiple department and multiple project management.
  • Current possession of, or ability to attain, risk management certification from accredited entity.

Application Instructions

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