Compliance and Risk Manager

Join to apply for the Compliance and Risk Manager role at Bournewood Health Systems2 days ago Be among the first 25 applicantsJoin to apply for the Compliance and Risk Manager role at Bournewood Health SystemsDescriptionThe Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws.DescriptionThe Compliance and Risk Manager is responsible for developing, implementing, and overseeing the hospital’s compliance and risk management programs. This includes ensuring adherence to standards set by the Joint Commission, the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), the Centers for Medicare & Medicaid Services (CMS), and all applicable state and federal laws.The position promotes continuous regulatory readiness, supports the hospital’s Quality Improvement (QI) Plan, manages incident reporting and risk reduction activities, and provides education and consultation to staff and leadership regarding compliance and risk standards.Essential Job FunctionsCompliance & AccreditationServe as the hospital’s subject matter expert for regulatory standards, including:Joint Commission accreditation standards (Hospital Behavioral Health & Hospital Programs).CMS Conditions of Participation (psychiatric hospitals).DMH licensing regulations for inpatient psychiatric services.BSAS regulations for substance use disorder services.Maintain a system ofcontinuous survey readiness, including staff education, internal audits, and policy/procedure review.Develop and maintain compliance tracking systems to monitor performance against regulatory requirements.Draft, review, and oversee hospital policies, procedures, and protocols to ensure alignment with applicable standards and laws.Coordinate preparation for all regulatory and accreditation surveys and inspections.Oversee compliance with any Corporate Integrity Agreements (CIA), Memoranda of Agreement (MOA), or regulatory settlement agreements.Risk ManagementDevelop and oversee the hospital’s Risk Management Program, including incident reporting, investigation, and analysis.Lead or assign staff to conduct Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA) as required by Joint Commission and DMH.Monitor trends in adverse events, complaints, and near misses; identify opportunities for system improvements.Ensure timely reporting of sentinel events, critical incidents, and other required notifications to regulatory agencies.Collaborate with leadership on insurance, liability claims, and contract review from a compliance and risk perspective.Prepare reports for leadership, the Quality Committee, and the Board of Directors on compliance, risk, and safety performance.Quality Improvement (QI) IntegrationPartner with the Quality Improvement Coordinator to support the hospital’s 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.Lead or participate in interdepartmental Performance Improvement and Risk Committees.Promote a culture of accountability, transparency, and continuous improvement throughout the hospital.Education & ConsultationProvide ongoing staff training on compliance, risk management, and regulatory standards.Keep leadership and staff informed of regulatory changes, survey outcomes, and improvement initiatives.Serve as a consultant to hospital departments in meeting compliance and risk management requirements.QualificationsEducation:Bachelor’s degree in Nursing, Social Work, or related healthcare field required.Master’s degree in Nursing, Social Work, Healthcare Administration, or related field strongly preferred.Licensure/Certification:Current LICSW, RN, or LPN required.Certification in Healthcare Risk Management (CPHRM) or Healthcare Compliance (CHC) preferred.Experience:Minimum 3 years’ experience in compliance, risk management, or quality improvement in a healthcare setting (psychiatric or behavioral health preferred).Demonstrated knowledge of:Joint Commission Behavioral Health & Hospital Accreditation StandardsCMS Conditions of Participation for Psychiatric HospitalsDMH licensing regulationsBSAS standards (if applicable to program areas)Experience with incident investigation, regulatory reporting, and corrective action planning.Familiarity with insurance and healthcare contracts preferred.Core CompetenciesRegulatory Knowledge: Expert understanding of psychiatric hospital accreditation and licensing standards.Decision-Making: Ability to make sound, ethical, and compliant decisions within scope of munication: Strong written and verbal communication skills; ability to provide clear education and consultation.Analytical Skills: Skilled in data collection, analysis, and presentation to leadership.Leadership: Ability to lead committees, facilitate cross-departmental collaboration, and influence culture.Confidentiality: Maintain the highest standards of confidentiality and integrity in handling sensitive information.Seniority levelSeniority levelMid-Senior levelEmployment typeEmployment typeFull-timeJob functionJob functionFinance and SalesIndustriesHospitals and Health CareReferrals increase your chances of interviewing at Bournewood Health Systems by 2xGet notified about new Risk Manager jobs in Brookline, MA.Framingham, MA $165,000.00-$185,000.00 1 week agoBoston, MA $124,000.00-$280,000.00 1 month agoSenior Analyst, Risk and Controls (IA) - Leading Alternative Asset ManagerCambridge, MA $124,000.00-$197,000.00 1 week agoSenior Risk Management/Loss Control Consultant-Central MA/Boston-Metro (Field)Marlborough, MA $100,000.00-$120,000.00 2 weeks agoTreasury Manager, Capital Markets & RiskBoston, MA $117,000.00-$187,000.00 6 hours agoSr. Manager, Risk-Based Quality ManagementCambridge, MA $148,000.00-$204,000.00 2 months agoBoston, MA $124,000.00-$280,000.00 2 weeks agoRegulatory Risk & Compliance - Pharma/Med Devices, ManagerBoston, MA $99,000.00-$232,000.00 2 weeks agoMedical Staff Peer Review/Risk Manager 40 hours/week 8am-4:30pm $5,000 sign on bonus!Boston, MA $97,000.00-$164,000.00 5 days agoCompliance Manager, Investment ManagementBoston, MA $125,000.00-$150,000.00 1 day agoBoston, MA $100,000.00-$225,000.00 5 months agoHead of Treasury and GA Model Validation, Managing DirectorModel Validations Investment Risk ConsultantFixed Income Portfolio Manager, Emerging Markets DebtBoston, MA $100,000.00-$225,000.00 1 month agoSenior Third Party Risk Analyst (Hybrid)Boston, MA $78,000.00-$128,000.00 5 days agoVP, External Investment Management – Public EquitiesWaltham, MA $177,600.00-$255,300.00 3 days agoFirst Line Risk Sr Manager - Embedded BankingBoston, MA $112,064.00-$200,000.00 2 weeks agoWe’re unlocking community knowledge in a new way. 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Created: 2025-09-17