westborough Work Opportunities ∙ Page 1

JOIN A TEAM THAT'S MAKING A DIFFERENCE IN MENTAL HEALTHCARE

Westborough Behavioral Healthcare Hospital (WBHH) is a 117-bed psychiatric hospital that provides comprehensive psychiatric care for children, adolescents, and adults through acute inpatient stabilization and outpatient services. Under dynamic new leadership, we're building an exceptional workplace culture focused on outstanding patient care and employee satisfaction.

Our mission is to deliver compassionate, evidence-based treatment while ensuring patients and their families feel supported throughout their healing journey. We're committed to creating an environment where our dedicated team members can grow professionally while making a meaningful impact in their community.

Located conveniently in Westborough at Routes 495 and 9.

Advance your career. Advance mental healthcare.

Director of Risk Management, Performance Improvement and Compliance is responsible for developing, implementing, and overseeing the hospital’s risk management and compliance programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Centers for Medicaid & Medicare Services (CMS), and all applicable state and federal laws and regulations.

This position promotes continuous regulatory readiness, supports the hospitals Quality Improvement Plan (QI), manages incident reporting and risk assessment and reduction activities. This is a highly visible role and a subject matter expert who provides education and consultation to staff and leadership regarding compliance and risk standards.

Compliance & Accreditation

• Serves as hospital’s subject matter expert for regulatory standards including: Joint Commission, CMS conditions of participation, DHM licensing regulations for inpatient/outpatient psychiatric services.
• Maintains a system of continuous survey readiness, staff education, internal audits, and policy/procedure reviews.
• Ensures timely completion, implementation and submission of all necessary corrective action plans.
• Develops and maintains compliance tracking systems to monitor performance against regulatory requirements. Drafts, reviews, and oversees hospital policies, procedures, and protocols to ensure alignment with all applicable standards and regulations.
• Leads the Quality Assurance and Performance Improvement Committee as well as Patient Safety and Workplace Violence Prevention committee and drives strategies related to the design and continuous improvement of the QAPI plan and to improve the safety culture across the hospital.
• Develops and implements reporting infrastructures and ensures integrity of internal and external reporting.
• Collaborates closely with all department leaders and works seamlessly to communicate critical information at all levels - from frontline staff to senior leadership. Leads the execution of education and training to staff, improvement opportunities and initiatives through both formal and informal venues.
• Serves as both the HIPAA and Compliance Officer to establish and maintain policies, procedures, and practices to ensure the facility operates ethically and in compliance with all Federal and State Health Insurance Portability and Accountability Act (HIPAA) and all other relevant state and federal laws, regulations and professional standards.

Risk Management

• Develops and oversees the hospitals Risk Management Program, including incident reporting, investigation, and analysis.
• Collaborates with QAPI disciplines to complete a Root Cause Analysis for specified events and Failure Mode and Effects Analyses (FMEA) as required.
• Monitors trends in adverse events, complaints, and near misses; identify opportunities for system improvements.
• Ensures timely reporting of sentinel events, critical incidents, and other required notifications to regulatory agencies.
• Collaborates with leadership and legal team on insurance liability claims, and contract reviews from a compliance and risk perspective.
• Prepares reports for leadership, the Quality Committee, corporate office on compliance, risk, and safety performance.
• Oversees the Human Rights officer, reviews complaints and grievances to ensure appropriate resolution and identifies potential exposures.

Quality Improvement (QI) Integration

• Support the hospitals Performance Improvement Plan (PIP)
• Ensure risk management and compliance data are integrated into QI reporting
• Monitor and analyze CMS quality reporting measures and Joint Commission quality indicators applicable to behavioral health.

• Promote a culture of accountability, transparency, and continuous improvement.

Salary: $126,692 - $199,700

Requirements

Education: A bachelor's degree in healthcare administration or a related discipline required, Master's degree in healthcare related field preferred.

Certifications: Certified Professional in Healthcare Quality (CPHQ) highly desirable. 

Experience: Two or more years of experience in healthcare risk management, quality and/or compliance ideally in acute psychiatric hospital, with leadership, supervisory experience is essential for this senior position. 

Benefits

• 401K
• Health Insurance
• Dental and Vision Insurance
• Health Savings Account
• Employee Discount Program
• Employee Assistance Program
• Pet Insurance
• Paid Time Off
• Tuition Reimbursement
• Generous Associate Discounts