Chief Compliance Officer

PURPOSE OF POSITION:

Oversees and coordinates the development, maintenance, implementation, operation, and periodic revision of the organization’s compliance program. Assures that program is set up to facilitate that all organizational components are compliant with applicable Federal, State, Local and industry laws, regulations, and standards. Advises senior leadership and Board of Trustees on compliance risks facing the organization.

PRIMARY DUTIES AND RESPONSIBILITIES:

1. Plans, organizes, directs, and coordinates compliance program activities to help ensure that entity-level (e.g., hospital, home health agency) practices, policies, and procedures comply with Local, State and Federal law as well as applicable accreditation and ethical standards; identifies the necessary participants in the compliance plan development and administration process; estimates resources necessary to accomplish the implementation of the program.
2. Identifies and establishes standards to which employees will be held and the types of conduct which the compliance program is designed to eliminate; develops systems and methods for program implementation and evaluation; develops, implements, and monitors program processes.
3. Develops, initiates, maintains, and revises policies and procedures for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct; manages the day-to-day operations of the program.
4. Monitors legal compliance with organizational and entity-level policies and procedures and recommends corrective actions and solutions as appropriate.
5. Investigates or coordinates the investigation and resolution of alleged compliance violations and complaints whether from patients, employees, medical staff members, vendors, governmental agencies, or others.
6. Coordinates communication of compliance standards to all organizational employees; works with entity-level leadership as appropriate to develop effective compliance training, including appropriate introductory training for new employees and ongoing training for all employees and managers.
7. Directs the preparation of special and recurring reports and analytical studies on complex compliance-related issues; monitors and conducts periodic audits and activities in key risk areas to ensure compliance.
8. Serves as Chairperson of the organization’s Compliance Committees; provides ongoing advice and regularly reports to the CEO, Board and other senior leaders on the implementation, operation, and needs of the compliance program as well as the risks facing the organization and how such risks are being addressed.
9. Manages key channels for reporting of compliance issues and concerns without fear of retaliation.
10. Ensures appropriate employee and contractor screening is conducted to ensure that the organization does not hire or conduct business with individuals or entities that have been debarred from participation in federal programs.
11. Stays abreast of legislation, trends, and issues pertaining to key risk areas; confers with knowledgeable individuals and advisors regarding potential impact of key legislation and court decisions; recommends and implements strategies to address new developments.
12. Participates in organizational strategic planning activities; serves on committees and task forces to address specific issues and/or represent the department as assigned; attends meetings and conferences as assigned; participates on task forces and committees as assigned.
13. Prepares and administers assigned budgets; monitors, evaluates, and approves operational expenditures within limits of authority; performs cost/benefit analyses as appropriate; plans and estimates future costs including capital expenditures as appropriate; justifies requests for new equipment and/or personnel.
14. Prepares filings for and may serve, when appropriate, as a liaison between the organization and federal, state, and local regulatory agencies.
15. May recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action for organization’s compliance personnel.
16. Performs other duties as needed.
17. Consistently provides, promotes, and projects service excellence to all patients, family members, visitors, volunteers, and co-workers.
18. Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.

EDUCATION/EXPERIENCE/TRAINING:

• 10 or more years of increasingly responsible professional or analytical experience in a health care institution that included responsibility for administering and monitoring compliance activities, including at least 5 years in an acute care hospital setting. Experience should clearly demonstrate skill in administering healthcare compliance program functions and activities.
• Bachelor’s degree in health care administration, business administration, public administration, finance, health science, or a closely related field or Master’s degree preferred. Professional certification as Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (or comparable certification from like organization) is highly desirable.
• Thorough knowledge of Local, State and Federal laws, rules, regulations, and ordinances pertaining to health care organizations, including but not limited to acute care hospital operations including the Joint Commission requirements and standards for acute care hospitals.
• Knowledge of principles, practices, and techniques of compliance management, including program planning, fiscal/financial analysis, basic accounting, program implementation, administration, and evaluation.
• Knowledge of best practices in developing and administering compliance programs and ability to evaluate the quality and effectiveness of the compliance programs and activities and make necessary improvements.
• Knowledge of principles and practices of business administration, including planning and organizing work, fiscal management, administrative problem solving, strategic planning and goal setting, and the implementation of effective solutions.
• Experience with computer-based business applications, including those commonly used for word processing, database management, spreadsheets, e-mail communication, and Internet access.
• Good familiarity with medical terminology.
• Ability to plan, organize, direct, and coordinate compliance activities within a healthcare system as well as plan, develop and implement effective compliance policies and procedures in accordance with organizational goals and objectives.
• Able to assess and investigate sensitive and complex administrative and operational issues, evaluate alternatives, and make logical recommendations based on findings.
• Able to communicate clearly and concisely, both orally and in writing, effectively present information to groups and individuals.
• Establish and maintain respectful and constructive working relationships with others including physicians, nurses, administrators, attorneys, managers, insurance carriers, and other stakeholders.