Compliance Director
3 weeks ago
The Compliance Director will report to the CCO and, when necessary, will have direct access to the Board of Directors to report and make recommendations about regulatory compliance issues. This position coordinates the planning, implementation, and maintenance of the organization’s compliance program. The position also oversees activities related to the implementation and adherence to Circle the City’s policies and procedures covering privacy and access to health information in compliance with federal and state law as well as oversees Circle the City’s Risk Management program to reduce errors in healthcare processes, improve health outcomes, and ensure patient safety.
Duties include, but are not limited to:
Reviews and revises the organization’s compliance plan as needed while utilizing Health Resources and Services Administration (HRSA) Compliance Manual.
Studies existing and new legislation, anticipated future legislation, and informs leadership of pending regulatory changes.
Participates in trainings related to compliance activities.
Oversees, develops, and provides compliance training and serves as a resource for all staff.
Collaborates with other departments and leadership to perform internal compliance audits or monitoring activities, and investigates and resolves compliance issues.
Oversees ongoing compliance for the HRSA Operational Site Visit.
Consults with attorneys and other resources as needed to resolve difficult legal compliance issues.
Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
Coordinates policy and procedure development and implementation for all departments.
Facilitates and assists with Federal Tort Claims Act (FTCA) compliance, including collaboration with the Chief Medical Officer (CMO) in completion of the FTCA redeeming application annually.
Coordinates and assists with the State licensure process.
Plans and contributes to the development of risk management systems. Monitors, investigates, and reports patient adverse events, malpractice claims, incident reports, and any indicators of potential harm identified.
Gathers risk-related data from internal and external sources, identifies and analyzes areas of potential risk, and informs leadership on how to manage and control key risks.
Reviews current literature or other resources for risk management and control.
Assists in development of tracking and reporting processes for medical record documentation, tracking of referrals and assessment of clinical outcomes.
Responsible for management and processing of all claims activities. Serves as the point person for communication with attorneys and the Federal Office of General Counsel. Periodically supports internal investigation in response to instances of loss, quality concerns, or undue risk exposure.
Responsible for management and processing of all subpoenas. Educates staff and serves as a resource when cases related to risk arise.
Functions as the co-chair of the Quality Assurance/Quality Improvement (QA/QI) Risk Management Committee.
Acts as the administrator for the incident reporting portal.
Regular and predictable attendance.
Continuous learning in both personal and professional development.
Consistent review, comprehension, and reply of company email and related correspondence.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty mentioned satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Graduate degree (M.B.A., M.A., etc.), plus 5 years related experience and/or training, and 3 years related management experience, or equivalent combination of education and experience.
Ability to write speeches and articles for publication that conform to prescribed style and format; Ability to effectively present information to executive leadership, public groups, and/or boards of directors.
Considerable responsibility with regard to general assignments in planning time, method, manner, and/or sequence of performance of own work, in addition, to the organization and delegation of work operations for a group of employees engaged in widely diversified activities.
Performs work operations that permit frequent opportunities for decision-making of minor importance and also frequent opportunities for decision-making of major importance, either of which would affect the work operations of medium organizational component and the organization’s clientele.
Required Certifications, Licenses, Registrations
CHCC (Certified Health Care Compliance), CCEP (Certified Compliance and Ethics Professional), or equivalent required.
Preferred Certifications, Licenses, Registrations
Community Health Center experience. Federally Qualified Health Center (FQHC) experience preferred.
Master’s Degree in nursing, health care administration, or closely related field.
Software skills required
Intermediate: Database, Presentation/PowerPoint, Spreadsheet, Word Processing/Typing
Advanced: Other
Additional software skills
HRSA Electronic Handbook; Compliatric (online incident reporting and regulatory compliance platform)
Physical and Mental Requirements
Position requires extended periods of sitting and standing;
Position requires regular bending and reaching, including transfer of patients;
Must be able to lift, carry and push 20 pounds on a regular basis;
Must be able to lift and carry up to 50 pounds on an occasional basis;
Comfortable in handling competing priorities in an occasionally high-stress environment.
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