Location Address:

Compensation Pay Range:

Summary:

Responsibilities:

Key Job Functions

• Enterprise risk assessment & program improvement: Evaluate risk management programs across the delivery system; identify gaps and trends; and recommend policy, workflow, and system changes to reduce exposure and improve loss control.
• Consultation, rounding, and education: Provide on-site and virtual consultative support through site visits, coaching, education, and communication that strengthen risk identification, reporting, resolution, and evaluation processes.
• Event response, investigation, and analysis: Respond to routine and urgent requests from leadership and Legal; direct and obtain preliminary investigative information; determine initial liability exposure; and guide mitigation actions and corrective plans.
• Claims, complaints, and pre-litigation resolution: Investigate incidents involving actual or potential injury to patients, visitors, and employees; manage potentially compensable events and required carrier notifications; collaborate with attorneys/adjusters; and support timely pre-litigation settlements within delegated authority.
• Regulatory, accreditation, and agency reporting: Maintain current knowledge of applicable regulatory and accreditation standards; ensure compliance with reporting requirements (including to the NM Health Care Authority and other agencies as required); and support investigations and corrective action planning.
• Clinical documentation and medical record review: Perform detailed medical record reviews, timelines, and summaries to support claim resolution and anticipated litigation; and assist with subpoenas, board/regulatory/insurance inquiries, and policy compliance reviews.
• Cross-functional partnership: Serve as a clinical risk management resource and educator for Legal, Compliance, Quality/Patient Safety, Patient Relations, Privacy, and operational leaders; answer emergent/urgent inquiries from clinical workforce and providers. Support Privacy investigations; and partner with Compliance investigating hotline complaints and documentation/billing concerns.
• Committee and governance participation: Actively participate in quality and patient safety initiatives and related committees across the Presbyterian Delivery System; contribute to quarterly internal/external counsel claim reviews and reserve-setting activities.
• Reporting and communication: Provide periodic reports to the Director, administration, and Boards regarding sentinel events, trends, and action plans; develop and deliver routine and ad hoc education on risk management and loss mitigation.
• Special investigations (as directed by Legal): In collaboration with and at the direction of Legal:
  • Complete detailed medical record reviews, timelines, and summaries to support investigations and Legal review (e.g., potential EMTALA concerns, complex discharges, and clinical diagnosis/treatment questions).

• Validate documentation of the patient’s identified decision-maker and authority (e.g., guardianship, medical or durable power of attorney) and supporting records relevant to decision-making for incapacitated patients.
• Support subpoenas and external inquiries by reviewing medical record documentation, staff assignments, and patient care issues for Medical/Nursing/Ancillary boards, regulatory agencies, insurers, and other investigative bodies.
• Analyze and interpret complaints, unanticipated events, and other data related to medical staff, nursing, and ancillary personnel to support employment and/or Medical Staff Affairs reviews and investigations.
• Provide medical record reviews and supporting content for Medical Ethics consultations; state/federal inquiries; policy compliance reviews; and evaluation of patient care outcomes.
• Conduct investigations related to allegations of workforce to patient allegations of abuse, neglect, or exploitation. 

Qualifications:

Bachelor’s degree required. Experience in nursing or other clinical field required. Five to eight years’ experience in the clinical/managerial arena with involvement in risk management activities required. Proficiency in database and other computer programs desired

Detailed Responsibilities

Competencies

• Planning and coordinating organizational change.
• Anticipating & Addressing Customer Needs
• Functioning as an Effective Contingent Member
• Acquiring & Applying Superior Skills to achieve Quality Outcomes
• Functioning as an Effective Team Member in assisting Legal, Compliance, and Risk Management, and Patient Relations.

Skills

* SKILL-Ability to effectively interact with customers to understand their needs and explain data

* SKILL-Microsoft Office Suite; Claims Management platform, Press Gainey HRP platform

* SKILL-Strong interpersonal and negotiation skills

*SKILL – Influence change and work to outcomes to improve quality of care to members and patients 

* SKILL-Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, attorneys, insurance adjusters, physicians, and physician office staff using strong dialogue and customer service competencies.

* SKILL- Effective and persuasive written and oral communication

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services