Direct Claims Jobs in Raleigh, NC (NOW HIRING)

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Job Summary

The Site Director of Clinical Risk Management is responsible for leading and administering the risk management program for a designated facility or entity. Working in collaboration with and under the oversight of DUHS Risk Management leadership, this role ensures the proactive identification, evaluation, and mitigation of risks affecting patients, visitors, staff, and organizational assets.

The Site Director provides strategic and operational leadership for site-based risk management activities, including event review, claims management, regulatory collaboration, staff education, and critical event response. This role serves as a key advisor to entity leadership and partners closely with Patient Safety, Regulatory, Compliance, Legal Counsel, and Durham Casualty Company.

Key Duties and Responsibilities

Leadership & Program Oversight

Provide day-to-day leadership and operational oversight of the Risk Management function for the assigned site or entity.

Directly supervise Risk Managers and administrative staff responsible for managing risk management events and claims.

Plan, coordinate, and oversee the work of Risk Management staff, ensuring efficient and effective operations.

Develop staff capabilities through coaching, performance feedback, goal-setting, and professional development opportunities.

Provide On-Call support and timely consultation on risk related issues for entity leadership, staff and providers

Risk Identification, Investigation & Claims Management

Direct and ensure timely, thorough occurrence reviews, quality of care grievances and claim file management.

Establish, reinforce, and monitor investigation and response standards.

Evaluate individual files and trend data to identify risk patterns and emerging issues.

Determine and recommend appropriate financial reserve levels for claims in collaboration with the AVP of Risk Management and Legal Counsel.

Authorize claim settlements within limits established by University Counsel and Durham Casualty.

Collaboration & Stakeholder Engagement

Partner closely with hospital/facility leadership to coordinate and support site-based risk management activities.

Identify, evaluate, and manage risks that could impact patient safety, organizational reputation, and financial stability.

Collaborate with Patient Safety, Regulatory, Compliance, Safety, Duke Police, and Patient and Visitor Relations.

Participate in Root Cause Analysis, action plans, and leader follow up as needed

Provide risk management information to Medical Staff Services to support credentialing and privileging processes.

Participate in leadership committees, event response teams, and other entity forums as required.

Respond to urgent and emergent risk exposure matters, providing immediate administrative decisions and support.

Education, Reporting & Performance Improvement

Develop, deliver, and evaluate risk-focused education for providers, nurses, new employees, and other staff to promote patient safety and reduce claims exposure.

Provide risk management data, reports, and analysis to entity leadership, committees, and boards as required.

Conduct departmental performance improvement activities and support quality and patient safety initiatives.

Ensure compliance with regulatory requirements and internal reporting standards.

Compliance, Documentation & External Coordination

Ensure compliance with information reporting requirements for Durham Casualty and reinsurance standards.

Maintain accurate risk management data and documentation in accordance with DUHS and entity standards.

Support actuarial reviews and other processes required by Durham Casualty Company.

Stay current on national trends in healthcare risk management through participation in local and national conferences.

Additional Responsibilities

Support entity leadership during critical events and high-risk situations.

Assist in supporting the Safety Reporting System (SRS) within the entity.

Perform other related duties as assigned in support of Risk Management objectives.

Required Qualifications

Education

Master's degree in business administration, Hospital Administration, Law, Nursing, or a closely related field.

Experience

Minimum of five (5) years of progressive healthcare risk management experience.

Demonstrated experience in budgeting, staff supervision, claims negotiation, and financial reserve projection.

Certification

Certified Professional in Health Care Risk Management (CPHRM) - required.

Knowledge, Skills, and Abilities

Supervision and leadership

Budgeting and financial projections

Trend analysis and data interpretation

Interviewing and investigation skills

Personnel management and employment practices

Accounting and bookkeeping fundamentals

Insurance claims, billing, and collections