Job Description
Job Description
Job Summary: The Risk & Regulatory Specialist serves as a key member of the Quality & Patient Safety Department at the Brattleboro Retreat, a Joint Commission–accredited psychiatric hospital. This role is responsible for supporting organizational compliance with all applicable federal, state, and local regulatory requirements, including those from The Joint Commission, Centers for Medicare & Medicaid Services (CMS), and the Vermont Department of Mental Health (DMH). The Specialist will proactively identify and mitigate organizational risks, support accreditation and licensure readiness, lead or support event investigations, and partner with leadership to build a culture of safety, accountability, and continuous improvement.
QUALIFICATIONS:
- Bachelor’s degree in Nursing, Healthcare Administration, Risk Management, or related field required. Master’s degree preferred.
- Current Vermont RN license preferred but not required.
- Certification in Healthcare Quality (CPHQ), Patient Safety (CPPS), or Risk Management (CPHRM) strongly preferred.
- Minimum 3 years of experience in healthcare risk management, compliance, quality, or regulatory affairs.
- Experience in mental health/psychiatric hospital setting strongly preferred.
- Demonstrated knowledge of Joint Commission accreditation standards, CMS Conditions of Participation, and Vermont DMH regulatory requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Regulatory Compliance & Accreditation
Monitors, interprets, and disseminates updates to regulatory requirements from Joint Commission, CMS, DMH, OSHA, and other relevant agencies.
Coordinates and supports ongoing accreditation readiness, including leading tracer activities, maintaining evidence of standards compliance (ESC), and organizing mock surveys.
Supports DMH licensing requirements, including timely submission of reports, corrective action plans, and follow-up documentation.
Assists departments in developing and maintaining policies and procedures that meet regulatory standards.
Risk Management
Conducts proactive risk assessments across clinical and non-clinical areas to identify potential patient safety, compliance, or organizational risks.
Tracks, trends, and analyzes incidents, near misses, and sentinel events; prepares reports for leadership and governing bodies.
Leads and/or supports event investigations, including Root Cause Analyses (RCA), apparent cause analyses, and sentinel event reviews.
Partners with leaders and frontline staff to develop and monitor corrective action plans to mitigate identified risks.
Supports the RCA process and ensure timely closure of risk events.
Assists in developing and maintaining the Patient Experience Program.
Patient Safety & Quality Support
Collaborates with the Quality Department to align risk and regulatory initiatives with organizational safety and performance improvement priorities.
Assists with the management of the patient safety program, including integration of Vermont’s Six Core Strategies for restraint/seclusion reduction and workplace violence prevention standards.
Supports the hospital’s risk and quality dashboards with accurate, timely data.
Reporting & Governance
Prepares regular reports and presentations for the Quality Council, Patient Safety Committee, Medical Executive Committee, and Board of Trustees.
Maintains documentation for state and accreditation surveyors and ensures timely submission of required regulatory reports (e.g., DMH, CMS).
Supports the hospital’s risk and quality dashboards with accurate, timely data.