Director of Compliance - Compliance and Innovation - Manning

The primary goal of the El Rio Health

Director of Compliance is to support El Rio’s Mission of providing comprehensive, quality health care that is affordable and accessible to all who may have healthcare needs, by successfully performing the primary essential functions.\nEssential Job Functions : \n\n\n\nEvaluates new and existing services and procedures to determine if they present a compliance risk to the organization and assists with countermeasures to improve the service in cooperation with the Chief Compliance and Risk Officer.\nInvestigates compliance concerns for severity, frequency, and probability of financial loss, and reports as necessary to appropriate administration, committees, and personnel. \nCompletes an incident for compliance concerns and investigates and establishes a plan that may include policies, educational programs, and reporting methods for the appropriate areas. Directs information on incidents as appropriate to staff. Uses industry benchmarking to compare appropriate data.\nParticipates in routine rounding, tracing, and monitoring of all clinical areas to identify and remediate areas of compliance nonadherence.\nIdentifies through the review of events, problems, patterns, and trends that reflect opportunities for correction, prevention, and improvement.\nDevelops and implements a comprehensive program to respond to any legal inquiries related to patient grievances or quality of care concerns filed with state medical, dental, pharmacy, behavioral health, or nursing boards. Trains and assists staff in responding to all state boards inquiries.\nDemonstrates and role models behavior regarding proper customer satisfaction, conduct, confidentiality, complaint resolution, and problem solving.\nProvides compliance education for the leadership team, professional staff and employees concerning methods for decreasing compliance risk.\nAdheres to El Rio Health organizational and department-specific safety, confidentiality, values, policies, procedures, and standards.\nReviews the Compliance Plan annually and makes recommended changes with updates to compliance policies and procedures as required.\nAssists and helps to establish strategic goals for compliance by gathering pertinent business, financial, service, and operational information. Identifies and evaluates trends and options, chooses a course of action, and evaluates outcomes related to compliance.\nPrepares activity reports and updates to inform management of the status and implementation and goal achievement related to the Compliance Plan.\nEstablishes work schedules and assignments for staff, according to workload, space, and equipment available.\nCompletes responses to external audits including but not limited to First Tier Downstream Related Entities (FDR) audits from contracted health plans.\nConducts periodic compliance risk assessments; 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 the future; produces written reports based on audit and risk assessment findings and remediation progress.\nCollaborates with Human Resources and other departments to develop and maintain the organization’s policies and procedures.\nResponds to alleged violations of rules, regulations, policies, and procedures by evaluating or recommending the initiation of investigative procedures. Acts as an independent reviewer to ensure that compliance issues / concerns within the organization are being appropriately investigated and resolved.\nMonitors and coordinates compliance activities of the organizations. In conjunction with the Chief Compliance and Risk Officer investigates / resolves difficult compliance concerns and recommends action plans to address recurring issues.\nWorks with Human Resources and health center leadership and others as appropriate to develop and carry out an effective compliance training program including appropriate introductory training for new employees as well as ongoing training for all employees and managers.\nSupports health center requests for guidance on compliance issues.\nDevelops guides and resources on compliance topics and provides training, knowledge, and skills to staff.\nIn collaboration with the Chief Compliance and Risk Officer / HIPAA Privacy Officer, oversee, update, develop, and implement compliance policies and procedures.\nIn concert with the Chief Compliance and Risk Officer / HIPAA Privacy Officer will be responsible for all duties associated with HIPAA compliance, including the investigation of, and reporting of HIPAA violations and the composition and delivery of responses to state regulatory agency complaints and inquiries.\nAssists in leading in the organization’s efforts for the HRSA On-Site Visit, including gathering documents, ensuring reviews and approval of policies and procedures.\nIn collaboration with the Chief Compliance and Risk Officer / HIPAA Privacy Officer and investigator, review HIPAA regulations for technology management and participate in conducting required controls, including periodic Risk Assessments.\nEnsures that the HHS OIG's List of Excluded Individuals and Entities and the General Services Administration's (GSA's) List of Parties Debarred from Federal Programs have been checked with respect to all employees, provider staff, and independent contractors, and vendors.\nAssists the Chief Compliance and Risk Officer with monitoring of the Compliance Hotline and independently investigates allegations of noncompliance and monitors appropriate corrective action and / or subsequent compliance.\nServes as the Vice Co-Chair of the Corporate Compliance and the Risk Management Committee.\nConducts an annual enterprise compliance risk assessment for the organization.\nImplements and monitors corrective action plan and / or subsequent compliance developed after compliance investigations.\nMaintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position.\nDemonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.\nAccomplishes department objectives by managing assigned staff; planning and evaluating department activities.\nSupervises, plans, organizes, and over sees operations for assigned areas. \nServes as a resource to assigned staff regarding specific skill demonstration, promotion of knowledge and communications.\nEstablishes, communicates, and develops means to implement standards of expectation, performance, and behavior for assigned department(s).\nAchieves and maintains departmental compliance with all relevant legal and regulatory standards and expectations.\nMaintains knowledge of current trends and developments.\nMonitors health information management systems, services, and staff performance to ensure data quality and integrity.\nProvides education and training to health center staff in areas relevant to policies and procedures.\nIdentifies and analyzes the design of jobs, work processes, workflows for assigned staff / departments and implements appropriate changes to improve effectiveness, efficiency, and productivity to support the overall goals of the organization.\nServes on standing and ad hoc medical, administrative, and department leadership committees, and serves as a resource to other departments to resolve problems that arise both within and outside of assigned staff / departments.\nReviews, evaluates, and updates departmental position descriptions, policies, and procedures annually as necessary to comply with regulatory, licensing, accrediting, and HIPAA requirements.\nServes as a resource to supervisory staff regarding specific skill demonstration, promotion of knowledge and communications.\nEstablishes, communicates, and develops means to implement standards of expectation, performance, and behavior for assigned staff / departments.\nAchieves and maintains departmental compliance with all relevant legal and regulatory standards and expectations and incorporates knowledge of current trends and developments.\nOversees the management and security of patient health information, ensuring compliance with federal, state, and local regulations.\nDevelops and implements policies and procedures to ensure efficient operations and high-quality service.\nManages the selection, training, and evaluation of leadership / supervisory staff, fostering a collaborative and productive work environment.\nCoordinates with IT department to oversee the implementation and maintenance of electronic health record (EHR) systems, ensuring system reliability and accessibility for authorized personnel.\nConducts regular audits of processes to identify areas for improvement and ensure compliance with changing healthcare laws and regulations.\nRepresents assigned department(s) in interdisciplinary committees within the healthcare facility, contributing to policy development and strategic planning initiatives.\nLeads compliance monitoring to identify process gaps, validate compliance levels, map processes, draft corrective actions / remediation plans, oversee implementation of corrective actions, prepare reports / presentations.\n\n\n\nMinimum Education and Experience : \n\nBachelor’s degree in business administration, healthcare administration, health Information management or a related field from an accredited college or university.\nSeven (7) years” supervisory experience; preferably in a healthcare environment.\nSeven (7) years progressive experience in a leadership role performing Compliance or Health Information Management or auditing functions, analysis, and reporting in a healthcare environment.\nCoursework in ethics, regulatory affairs, health information, and corporate governance.\nProficient in the use of Electronic Health Record and Microsoft Office products.\n\nIf applicable, an equivalent combination of education and experience may be considered and must be directly related to the functions and responsibilities of the job.\nRequired Licenses, Certifications, and Registrations : \n\nCertification in Healthcare Compliance (CHC) or Compliance and Ethics Professional (CCEP) is preferred or obtained within the first year of employment.\n Level I fingerprint clearance card : current valid and in good standing or have applied for it within seven working days after beginning employment.\nEmployees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday. If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.\n\nPreferred Education, Experience, Skills, Abilities : \n\n Master’s degree in healthcare related professional field from an accredited university. \n Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) credential. \n\nCurrent Registered Nurse License in good standing from the Arizona Board of Nursing or other advanced level clinical healthcare professional field.\nThree (3) years’ nursing experience for candidates as applicable.\n\n\n Bilingual (English / Spanish) with the ability to speak, read and write in both languages.\n\nEl Rio Health is a diverse and inclusive organization. We are invested in helping you and your family Create Tomorrow.\n