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Dir, Patient Safety/Regulatory Readiness Job

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Date: Sep 3, 2021

Location: Memphis, TN, US

Company: Methodist Le Bonheur Healthcare


Responsible for managing the process for continuous regulatory and accreditation compliance, clinical risk management program and infection prevention program for the assigned physician practices.   Serves as advisor and subject matter expert in DNV, CMS and other regulatory agency standards.  Plans, administers, and implements processes to support ongoing compliance and survey readiness.  Responsible for the proactive risk assessment that includes, but may not be limited to, administering the clinical risk management program on a day-to-day basis, managing and analyzing risk management data, and conducting risk management educational programs, with the overall objective of promoting patient safety, enhancing quality of care and minimizing loss to protect the assets of the practices.   Responsible for monitoring the physician practice environment for appropriate infection control and prevention practices, for collecting and evaluating surveillance data for the preparation of necessary reports for various committees, and for assistance in educational programs related to infection control and prevention. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.



Education/Formal Training

Work Experience




Bachelor’s Degree in Nursing, Healthcare Administration, or related clinical field.


Minimum of five (5) years of experience in hospital risk management, patient safety, or clinical quality management.



Licensed as a Registered Nurse in the state where work is performed.




Master’s Degree in Nursing, Healthcare Administration, or related clinical field.
















  • Demonstrated knowledge and expertise in regulatory standards established by DNV and CMS applicable to acute care hospitals, ambulatory services and hospital based practices.
  • Strong communication skills including excellent verbal, written and presentation with experience in conveying complex information to management and all levels of Associates, physicians, attorneys, management, patients and their families.
  • Demonstrated capability in facilitating a collaborative approach to compliance with regulatory standards.
  • Ability to consult and negotiate in situations that are controversial and/or sensitive that result in mutual decisions. 
  • Ability to read and interpret complex statutes and regulations and apply knowledge to manage compliance risk exposure.
  • Knowledge of statutes and case law relative to health care providers.
  • Skills in developing and implementing creative and aggressive methodologies for investigating and resolving HPL/GL claims.

Key Job Responsibilities

Risk Management

  • Develops, coordinates, and administers practices for risk identification, investigation and reductions.  Performs risk assessments and inspects patient care areas, and reviews claims data to assess loss potential.
  • Represents Clinical Risk Management on safety, quality and other committees; partners with other team members to recommend and implement procedures that promote patient safety and limit liability exposures.
  • Reports, investigates, collects, evaluates and distributes relevant data concerning incident reporting, near miss reporting, and significant events.  Aggregates data and prepares reports and analyses to review progress and trends. Recommends corrective actions based on individual reports or trends.
  • Directs or investigates risks involving actual or potential injury or harm to patients and visitors; collects information necessary to prepare reports for administration and claims department.  Collaborates with claims department to respond to claims or inquiries.
  • Oversees or reports patient care incidents as required by law; directs investigations and developments of corrective action plans; submits required reports to state and federal agencies.
  • Collaborates with Clinical Education Services & Organizational Development to present in-service education on clinical risk management topics to include both standard basic education and complex focused topics designed to minimize the frequency and/or severity of safety hazards and liability exposures.

Regulatory Readiness

  • Manages the process for continuous regulatory and accreditation compliance for the assigned physician practices.
  • Assists in development and implementation of regulatory strategies for the system.
  • Serves as advisor and subject matter expert in DNV, CMS and other regulatory agency standards.  Plans, administers, and implements processes to support ongoing compliance and survey readiness.
  • Develops and coordinates the measurement of internal compliance through data collection, tracking/trending, analysis, and monitoring.  Presents findings and recommendations for improvement.
  • In coordination with the senior management and other leaders, plans, implements, and administers programs to assess state of readiness for surveys, focusing upon continual preparation.
  • Prepares and coordinates responses to regulatory agencies on corrective action plans, inquiries, and other requested information.
  • Serves as the subject matter expert and resource for DNV accreditation standards and accreditation requirements. Acts as an advisor to clinical practice in the development of policies and procedures to ensure DNV standards are met or exceeded.
  • Coordinates educational activities and programs regarding clinical and regulatory standards through the organizational directors.
  • Participates as a team leader or member in system or facility performance improvement/regulatory readiness teams.  Builds mutual trust and encourages respect and cooperation among team members to support movement from current state of practice to desired state of practice, address and mutually resolve issues.
  • Provides tools and resources to facility to meet MH corporate, divisional and departmental goals and objectives while participating in leading the development of policies related to the Regulatory Readiness program.

Physical Requirements

  • The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
  • Must have good balance and coordination.
  • The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
  • The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
  • The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.
  • Travel to all MLH facilities, attorney offices, presence at trials, mediations, depositions, etc.
  • Maintain 24-hour availability for needed activities/situations in the event of emergencies.

Nearest Major Market: Memphis

Job Segment: Regulatory Affairs, Safety, Medical, Law, Claims, Legal, Service, Healthcare, Insurance