Claims Manager Jobs in Rochester, MA (NOW HIRING)

Job Description Summary

We’re looking for a Clinical Risk Manager who is passionate about patient safety, high‑reliability practices, and driving meaningful system‑wide improvement. The Clinical Risk Manager supports South Shore Health’s system‑wide efforts to improve patient safety, reduce risk, and ensure regulatory compliance. This role conducts event investigations and root cause analyses, identifies trends, and partners with clinical and operational leaders to develop effective corrective actions. The position also assists with claims management, regulatory readiness, external reporting, and participates in a 24/7 on‑call rotation. In this role, you’ll: Lead investigations and root cause analyses Identify trends and system risks through data and event review Partner with clinical + operational leaders to implement corrective actions Support regulatory readiness, accreditation, and required reporting Contribute to claims management and patient safety initiatives Help cultivate a culture of safety across the organization Who we’re looking for: 🔹 MA RN license 🔹 Bachelor’s degree (Master’s preferred) 🔹 3+ years experience in hospital or health‑system risk management 🔹 CPHRM, CPPS, or CPHQ (or willing to obtain within 1 year) 🔹 A collaborative communicator with strong analytical and problem‑solving skills

Job Description

ESSENTIAL FUNCTIONS

Risk Management

• Participates in planning, implementing, managing, monitoring, and documenting an integrated, comprehensive and proactive risk management program for SSH.
• Collaborates with Patient Safety, Regulatory/Accreditation, Compliance, Quality Management, Office of Patient Experience and departmental quality and operations leaders to identify and assess unusual incidents, unexpected outcomes, and potential risks, translating learnings into the development of loss and error prevention strategies. 
• Serves as internal consultant and facilitator for quality improvement committees and teams
• Recommends corrective and preventive actions to reduce risk. Collaborates with insurer and hospital-based improvement teams on interventions.
• Reviews and evaluates aggregate adverse events and claims data, as well as other hospital information in order to identify high-risk activities, procedures and departments.
• Performs root cause analysis on all serious reportable events (SREs) and other events as appropriate. Supports staff in investigation/review process, debriefs, corrective actions and follow-up.  Completes required reporting and documentation in accordance with legal, regulatory, accreditation standards and requirements.
• As requested, serves as institutional liaison to professional/general liability insurers.
• Ensures appropriate and timely communications with health system and departmental leadership concerning professional/general liability matters.
• Under the direction of the Executive Director of Risk, Senior Clinical Risk Manager and the Office of General Counsel, assists in the claims management process for the hospital including directing management of legal claims involving hospital and staff and collaborates with insurers, as needed.
• Assists with supporting and coordinating Medical Staff Peer Review Committees, working closely with Medical Staff leadership, providing accurate clinical summaries, data trending, reports and analysis.
• Collaborates with the Patient Experience Department to assist in reviewing patient grievances. Works with team, as appropriate to respond to patient grievances.
• Partners with colleagues across the organization to coordinate and facilitate risk and safety education, complete collaborative risk reviews, and develop robust action plans.
• Integrates risk management program activities with clinical programs, hospital and health system operations and administration, such as patient safety, regulatory/accreditation compliance, patient care services, environmental safety, human resources, infection control, occupational health, clinical laboratories, physician services, information management, compliance/privacy, etc.
• Participates on the Quality Council, Joint Commission Core Team, Environment of Care Committee, and other committees, as need is identified.
• Development of institutional communication and education strategies related to Risk Management, quality and patient safety issues and compliance with emerging regulatory, case and statutory law.
• Participates in on-call schedule to enable 24/7 coverage for inquiries on risk management matters.

Patient Safety

• Performs comprehensive system analysis of patient safety events utilizing just culture principles and standard processes.  Focuses on high reliability concepts when developing improvement initiatives.
• Reviews adverse event reports to ensure timely and appropriate analysis and follow up.
• Performs data analysis of safety event reporting relative to adverse incidents to identify trends, and signals of risk.
• Plays vital role in the management of risk /safety reporting systems, including but not limited to file management, user set-up and training, and reporting.

Regulatory/Accreditation

• Serves as internal consultant to the health system departments and leaders on matters of regulatory compliance and other health care related regulations, laws, and standards.  Appropriately involves SSH Office of the General Counsel and Compliance & Privacy Department as needed.
• Maintains current and accurate knowledge of regulations, laws and standards pertaining to SSH, including but not limited to FDA, TJC, DPH, and CMS Medicare Conditions of Participation.
• Supports all regulatory related certifications and accreditation activities including mock surveys, tracers, intra-cycle monitoring assessment, management of site visits, and post survey follow up.
• Reviews and evaluates results of regulatory/accreditation surveys and mock surveys to ensure policies and procedures support safe, compliant practice.
• Participates in review and development of relevant institutional policies.

JOB REQUIREMENTS

Minimum Education - Preferred

Bachelor of Science in Nursing or other health related science from an accredited school

Masters preferred

Minimum Work Experience

3+ years Hospital or Health System Risk Management experience

Required Licenses

Current MA RN licensure

Required Certifications

CPHRM (Certified Professional in Healthcare Risk Manager) or

CPPS (Certified Professional in Patient Safety) or

CPHQ (Certified Professional in Healthcare Quality)

Above certifications required within one year of hire.

Required additional Knowledge and Abilities

• Strong interpersonal and leadership skills to lead and direct system-level IPC program.
• Ability to collaborate and partner across all levels and functions within the organization.
• Possesses strong analytical skills to identify and monitor practice patterns and trends and identify opportunities for improvement.
• Experience with data analysis software and applications (i.e., Microsoft Excel, Redcap, RL Datix)
• Requires strong organizational skills to manage many competing timetables and responsibilities. The ability to delegate, effectively supervise and plan for the timely and successful completion of short and long-term objectives is essential. The responsibilities of this position require detailed, concentrated effort and constant re-establishment of priorities as well as complex and sensitive decision-making.
• Possesses strong communication skills to serve as liaison to internal and external stakeholders. Requires superior skills in financial, written, and oral formats.
• Ability to interact with all members of the organization in ways that enhance understanding, respect, collaboration and problem solving.

Leadership Competencies

• Passion for and commitment to the organizational mission and serving as a key member of the organizations leadership team.
• Sets an honest, transparent and positive tone in all areas and works in concert with leadership, medical staff and other members of care delivery to establish a collaborative environment.
• Strong communication skills in all venues; strong focus on listening to understand.
• Solutions-oriented coupled with the ability to function well in a culture that values relationships and collaborative decision-making.
• Ability to serve as a role model in commitment, engagement, and accountability for the provision of outstanding patient care.
• Ability to mobilize teams for common goals and shared vision.
• Positive change agent who builds a solid infrastructure and organizational foundation.
• Value driven commitment to the provision of quality, safety and patient/family centric healthcare services.
• Ability to proactively identify problems, lead change, and overcome obstacles.
• Data driven, results-oriented style with a high degree of analytical ability and proven problem-solving skills.
• A team player who can build collaborative relationships across the organization.
• Able to proactively cultivate new and innovative approaches and solutions to infection prevention and control issues that promote the mission, vision, values, and culture of South Shore Health.