Responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues.  Provides intervention and education related to risk management issues to promote safe work practices and quality care and services; in an environment that is beneficial to the safety, health and well being of all patients, visitors and hospital staff.  Coordinates risk programs with all hospital departments and administration.  Reports real and potential risk situations to the Governing Body, medical staff, administration, hospital departments, and committees, as appropriate.  Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.


Works at maintaining a good rapport and a cooperative working relationship with physicians, departments, and staff.  Resolves personnel concerns at the departmental level, utilizing the grievance process as required.  Ensures compliance with policies and procedures regarding department operations, fire, safety, and infection control.  Effectively and consistently communicates administrative directive to personnel and encourages interactive departmental meetings and discussions.



  1. Knowledge of human anatomy, physiology, and the general medical field.

  2. Knowledge of basic components of risk management, including potentially compensable events, risk investigation, reporting and claims management.

  3. Ability to perform medical record review for the purpose of identification of real or potential risk and the monitoring of documentation practices.

  4. Ability to prepare risk identification reports for submission to the organizational risk carrier.

  5. Ability to prepare risk identification reports in summary format, for presentation to hospital administration, the medical staff, and the Governing Body.

  6. Refers information gathered from risk identification reporting to the appropriate department manager/administrative personnel member and/or hospital mechanism for analysis and corrective action to eliminate or reduce risk.

  7. Communicates appropriately and clearly to physicians, staff, Nurse Executive, and administrative team.

  8. Summarizes risk management data for appropriate evaluation and risk trend analysis.

  9. Advises hospital staff, medical staff and/or committees regarding real or potential liability situations.

  10. Advises clinical staff regarding patient care to ensure patient’s needs are met and hospital policy is followed.

  11. Maintains a good working relationship with administration, medical staff, and all hospital departments.

  12. Demonstrates an ability to be flexible, organized and function under stressful situations.

  13. Consults other departments as appropriate to collaborate in patient care and performance improvement activities.

  14. Interacts professionally with patient/family to increase patient/family satisfaction and/or diffuse potential litigious occurrences related to patient/family perception.

  15. Treats patients and their families with respect and dignity.  Identifies and addresses psychosocial, cultural, ethnic and religious/spiritual needs of patients and their families.

  16. Maintains knowledge related to performance improvement activities throughout the hospital.

  17. Knowledge of appropriate and current documentation practices related to the risk management arena.

  18. Assists in development of policies and procedures related to risk management practices.

  19. Coordinates risk management, performance improvement, and patient relations information, as needed for administrative activities, and hospital insurers.

  20. Review, evaluates and recommends action on risk related matters pertaining to patients, visitors, employees, students, physical plant and personal property.



  1. Adheres to dress code, appearance is neat and clean.

  2. Completes annual education requirements.

  3. Maintains regulatory requirements, including all state, and federal regulations.

  4. Maintains and ensures patient confidentiality at all times.

  5. Reports to work on time and as scheduled.

  6. Wears identification while on duty.

  7. Attends annual review and performs departmental inservices.

  8. Represents the organization in a positive and professional manner.

  9. Attends committee, PI, and management meetings, as appropriate.

  10. Complies with all organizational policies regarding ethical business practices.

  11. Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.



Language Skills:

  • Ability to communicate in English, both verbally and in writing.

  • Excellent interpersonal skills.

  • Excellent presentation skills.

Physical Demands:

  • For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

Regulatory Requirements:

  • Previous experience with healthcare compliance programs preferred.

  • Skills:

  • Knowledgeable of all local, state, federal laws and regulations, facility vendors, government healthcare plans, and private payer health plans.

  • Basic computer knowledge.



            Position Reports to CEO



Bachelor’s degree in allied health, nursing, business psychology, science, or related field or equivalent years of experience in nursing or nursing administration.  Must understand EMTALA as well as HIPAA rules and regulations.