09 Sep Compliance Officer

The Compliance Officer oversees the Compliance Program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. The position ensures the Board of Trustees, management, employees and contractors follow the rules, regulations and laws of regulatory agencies, that hospital policies and procedures are being followed and the behavior in the organization meets the hospitals Standards of Conduct.

The Compliance Officer acts as a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolution and as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted.

Reports to: CEO

Responsibilities:

1. Develops, initiates, maintains and revises policies and procedures for general operation of the Compliance Program and its related activities to prevent illegal, unethical or improper conduct.
2. Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
3. Collaborate with departments (Risk Management, Quality Assurance, Medical Staff, Human Resources, Etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with hospital attorneys and outside consultants as needed to resolve difficult legal compliance issues.
4. Responds to alleged violations of rules, regulations, policies, procedures and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling such violations.
5. Acts as an independent review and evaluation body to ensure that compliance issues/concerns withing the organization are being appropriately evaluated, investigated and resolved.
6. Monitors and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
7. Identifies potential areas of compliance vulnerability and risk: Develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in future.
8. Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
9. Reports potential/actual violations to hospital’s liability carrier promptly  when a loss is identified.
10. Works with the Human Resources Department and others as appropriate to develop an effective training program, including appropriate introductory training for new employees as well as ongoing training for all employees and manager.
11. Monitors the performance of the Compliance Program and relates activities on continuing basis, taking appropriate steps to improve effectiveness.

Education and Experience/Skill Requirements

1. Bachelor’s degree required. Master’s degree preferred.
2. Minimum of 10 years experience in healthcare organization to include demonstrated leadership. Familiarity with operational, financial, quality assurance and human resources procedures and regulations.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1. moderate periods of sitting/standing/walking
2. pushing/pulling
3. lifting/carrying >= 50 lbs.
4. crawling         
5. climbing         
6. kneeling/bending
7. visual acuity   
8. hearing acuity

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