Manager, Clinical Risk and Regulatory Management

City of Hope Orange County is transforming cancer treatment by bringing world-class expertise and specialized care closer to home. Supported by a regional network of care, our 11-acre academic cancer campus in Irvine is home to City of Hope Orange County Lennar Foundation Cancer Center, our outpatient cancer center, and Orange County’s only cancer specialty hospital, opening in late 2025.With the opening of the hospital, the full continuum of advanced cancer care—from prevention through survivorship—will be available in Orange County for the first time, eliminating the need to travel for lifesaving treatment. Seamlessly connected to our outpatient cancer center, the new clinical research hospital will feature 73 inpatient beds, advanced surgical suites, groundbreaking clinical trials, and holistic services such as rehabilitative therapy and spiritual care. This isn’t standard cancer care. This is lifesaving cancer care. This is Hope.

The Manager, Clinical Risk and Regulatory Management assists the Executive Director Risk, Quality & Safety in planning, directing, coordinating, and leading the risk management, regulatory and patient safety program across the Orange County Regional Network. Assists in new program development. Collaborates with the medical staff and leadership to ensure regulatory requirements are met, patient safety initiatives are in place and promote a culture of safety. Directly manages risk management, survey readiness and patient safety/risk programs that assess, measure, and analyze data to direct process improvement to ensure compliance with regulations/standards and support COH’s mission, vision, values, and strategic initiatives.

The Manager, Clinical Risk and Regulatory Management directs the regulatory management program, oversees performance improvement activities, and supports all activities to ensure successful review by all regulatory and accreditation bodies such as The Joint Commission (TJC), California Department of Public Health (CDPH), and Centers for Medicare and Medicaid Services (CMS).

Directs the patient safety and risk reduction program through coordination of proactive risk assessments, review of incidents and insurance grievances, designs and implements risk reduction strategies and coordinates Failure Mode and Effect Analysis (FMEA) and root cause analyses (RCA) when indicated to identify and mitigate risk.

Directs and oversees survey activities and regulatory compliance with particular focus on TJC, , CDPH interactions for complaints, surveys and facility renovation and expansion, accreditation and other accrediting /regulatory bodies as needed.

As a successful candidate, you will\:

• Identify and evaluate performance of meaningful clinical risk metrics.

• Communicates hospital performance to the board of directors by working with the Executive Director Risk, Quality & Safety on reports regarding clinical risk areas.

• Communicates with relevant parties and the Policy and Procedure Manager regarding integration of findings, regulations, and suggestion to improve policy and procedures.

• Performs benchmarking of performance against industry leaders.

• Provides education on high reliability, just culture and clinical risk information throughout the regional network.

• Based on a systematic and statistical analysis, creates, communicates and executes a strategy for clinical risk improvements.

• Supports the integration of lean tools in streamlining process and procedures related to clinical risk and the policy/procedure processes.

• Supports the implementation of evidenced based state and national clinical risk/patient safety initiatives.

• Visits offsite locations to meet and educate staff.

• Directs the personnel responsible for patient safety activities and risk mitigation enterprise wide.

• Directs the development of a patient safety/risk mitigation plan, manages to activities and reports on progress toward goals to leadership.

• Oversees the acquisition, utilization, and analysis of data from numerous sources (i.e., TIPs, grievances, legal action, insurance carrier feedback) into a workable plan to improve safety and reduce risk through prevention, detection and correction.

• Oversees FMEAs, RCA’ss and proactive risk assessments. Recommends and coordinates performance improvement and process redesign to enhance patient safety.

• Directs activities and staff to prepare for external surveys through updates, tracers, rounds, and education.

• Keeps abreast of regulatory changes and communicates those to the region and modifies processes as required.

• Develops and coordinates reports to external regulatory/accrediting bodies. Conduct gap analyses regarding standards and regulations. Report data as required and keep leadership informed of same.