Quality and Risk Manager

Job Summary:

The Quality & Risk Manager supports the Director of Quality & Performance Excellence by managing day-to-day quality, risk, regulatory readiness and corrective-action operations across Memorial Hospital of Gardena and Coast Plaza Hospital. The position is responsible for converting the Director's priorities into reliable daily workflows, maintaining accountability for open quality and risk work, coordinating survey readiness activities, supporting event review and investigation, and ensuring that identified corrective actions are implemented, monitored and closed.

The Manager serves as the operational backbone of the Quality Department. The Director retains executive accountability, strategic priority setting, high-risk event oversight and final escalation authority. The Manager coordinates departmental workflow and may provide administrative supervision or work directly with Quality Department staff as delegated by the Director, while the Director retains direct priority-setting and professional oversight for the two RN specialist roles.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions:

• Manage daily Quality Department workflow across both hospitals and ensure priorities, assignments, due dates and escalations are visible and actively managed.
• Coordinate risk-event intake, initial triage, routing and follow-up in collaboration with the Director and appropriate operational leaders.
• Support investigation of patient safety events, complaints, near misses, regulatory concerns and other quality/risk issues; escalate high-risk matters promptly to the Director.
• Maintain centralized trackers for corrective actions, Plans of Correction, survey findings, regulatory commitments, audits and other department deliverables.
• Coordinate continuous survey readiness activities, including tracers, mock surveys, evidence collection, departmental follow-up and validation audits.
• Partner with department leaders to ensure corrective actions have defined owners, deadlines, monitoring plans and evidence of sustained compliance.
• Support preparation for Joint Commission, CMS, CDPH and other regulatory/accreditation activity and coordinate real-time survey logistics as assigned.
• Monitor quality/risk work queues and aging, identify overdue items, remove operational barriers when possible and escalate unresolved issues to the Director.
• Coordinate daily and weekly departmental huddles, action-item follow-up and readiness activities.
• Support RCA, FMEA, event debriefs, high-risk case reviews and corrective-action development while ensuring appropriate handoff to the Quality Improvement RN for formal improvement projects when needed.
• Support policy review and implementation activities arising from regulatory findings, event investigations and quality improvement work.
• Prepare concise operational updates for the Director, including major risks, overdue actions, survey readiness status and areas requiring executive intervention.
• Coordinate with Patient Experience, Infection Prevention, Nursing, Medical Staff, Case Management, Pharmacy, Facilities, Laboratory and other departments on cross-functional quality/risk issues.
• Promote consistent quality and risk processes across MHG and CPH while recognizing site-specific operational requirements.

Risk Management Responsibilities:

• Maintain a reliable workflow for event review, department response, escalation and closure.
• Ensure high-severity or potentially reportable events are immediately escalated to the Director for determination and executive/legal/regulatory coordination.
• Support fact gathering, record preservation, interviews, chronology development and corrective-action tracking as assigned.
• Monitor recurrent event themes and coordinate handoff to the PI RN when a system-level project is indicated.

Regulatory Readiness Responsibilities:

• Maintain an active readiness calendar and open-findings tracker for both hospitals.
• Coordinate mock tracers, environment and clinical readiness follow-up, document requests and evidence collection.
• Track Plans of Correction, accreditation findings and regulatory commitments through implementation and sustainment verification.
• Ensure departments understand assigned corrective actions and required evidence; escalate incomplete or ineffective actions.
• Support survey command-center operations and post-survey action planning as assigned by the Director.

Department Management Responsibilities:

• Translate Director priorities into daily and weekly department work plans.
• Coordinate workload across the two hospitals to ensure urgent regulatory, risk and quality needs receive appropriate coverage.
• Provide administrative work directions, coaching and follow-up to Quality Department staff as delegated by the Director.
• Standardize tools, logs, templates and workflows to reduce variation between facilities.
• Monitor workload, turnaround times and capacity concerns and present resource needs to the Director.
• Support onboarding, competency development and cross-training of Quality Department personnel.

Behavioral Standard:

• Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude.
• Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.

Communication/Knowledge:

• Available to participate in on-call rotations and respond to department needs as required.
• Provides on-call support as needed to meet operational and departmental demands.
• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.

Collaboration/Teamwork:

• Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program.

Qualification/Experience:

• Minimum (2) years of hospital quality, risk management, regulatory, patient safety or closely related experience.
• Previous coordinator or manager experience in an acute-care hospital, preferred.
• Demonstrated experience managing projects, corrective actions, audits, survey readiness or cross-functional operational work.
• Strong organizational skills with ability to manage multiple deadlines across two facilities.
• Strong written and verbal communication skills and ability to work with frontline staff, physicians, department leaders and executives.
• Working knowledge of hospital accreditation, CMS Conditions of Participation, California hospital regulatory requirements and patient safety principles.