Compliance and Regulatory Affairs Officer

Position Summary: This is a highly responsible position that is directly under the supervision of the Chief Executive Officer. The person holding this position is expected to provide leadership, technical expertise, and management of the Corporation's Compliance/Risk Management Program. This individual also has supervisory responsibility for the organization’s Compliance staff. The person holding this position works in collaboration with the Senior leadership team as well as other organizational leaders.

Roles and Responsibilities:

• Serves as the health center designated individual (s) to oversee the Compliance/Risk Management program established by board- approved policy (ies). Responsibilities include, but are not limited to; ensuring the development, implementation, and update of compliance related operating procedures and related assessments, monitoring outcomes, ensuring development and execution of remediation plans, and other activities as required by HRSA guidelines.
• Provides leadership and oversight for Compliance Coordinators, ensuring proper execution and documentation of compliance activities as indicated. This includes but is not limited to: audits to identify potential weaknesses and noncompliant situations, management reports, and incident reports
• Keeps current with relevant OIG, CMS, DOH, OSHA, URAC, Federal/State/local regulations and laws, fraud alerts, and other regulatory agency rules and regulations.
• Educates staff and board regarding requirements for compliance with applicable laws, regulations, and program requirements.
• Leadership and execution of activities and initiatives to ensure compliance, and ongoing accreditation/recognition with entities including (but not limited to) HRSA, The Joint Commission, URAC, and PCMH.
• Ensures the CEO and Board of Directors (BOD) are informed regarding the organization’s Compliance/Risk Management status and issues.
• Ensures the annual review and update of the organization’s Compliance/Risk Management Plan.
• Ensures training (directly or via designees) regarding the Corporate Compliance plan, process, and activities for all employees and the Board of Directors.
• Co-Chairs (with leader of QI) Organizational and Board Quality Improvement/Compliance Committees to be held every month.
• Monitors laboratories, in conjunction with the Laboratory Coordinator, for compliance with CLIA regulations.
• Ensures that Florida State and CLIA licenses are current and up to date. Notifies appropriate agencies as changes are made.
• Oversight for the incident reporting process (receiving incident reports and reviewing them with the appropriate leadership staff). This also includes providing direction for completing root-cause analysis (RCA) and recommending performance improvement plans in response to adverse incidents.
• Submits monthly non-clinical quality and risk management reports to leadership and the Board of Directors (BOD). This includes information regarding FCHC Quality Measure performance and associated non-clinical QI/QA activities. Regularly provides updates regarding TJC and PCMH status to the BOD. Leads the monthly BOD QI Committee. Assures the BOD reviews and approves the Corporate QI/QA and Compliance plans no less than annually.
• Works with Senior and Center leadership to assist and ensure compliance with the QI Plan and Corporate Compliance Plan with internal (policy/procedure) and external (contract/program) requirements.
• Maintains employee hotline and monitors for complaints and potential fraud/abuse reports.
• Responsible for ensuring investigation of all reports of potentially improper/illegal activities and reporting of results to CEO and Board of Directors.
• Responsible for handling and responding to medical malpractice claims or allegations (compiling medical records, completing documentation responses for Administrative Tort Claims and informational requests, and disseminating litigation hold notices) and providing routine status updates.
• Responsible for oversight of Medical Records function and staff.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• Must have at least five (5) years’ experience in compliance related activities and management experience.
• Must possess a minimum of a bachelor’s level degree level degree in related field

COMPETENCIES

• Excellent leadership, communication, and interpersonal skills.
• Knowledge of current Federal, State, and local laws and regulations.
• Knowledge of HRSA, the Joint Commission, URAC and NCQA PCMH requirements
• Must be able and willing to routinely travel within six (6) county service area to Center locations and outside the area as needed for workshops and/or conferences.
• Excellent Customer Service
• Model the mission, vision, and values of FCHC.

This job description is not intended to be all-inclusive, and employee will also perform other reasonable related business duties as assigned by supervisor.

* This organization reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract of employment*.

Job Type: Part-time

Benefits:

• 401(k)
• 401(k) matching
• AD&D insurance
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Work Location: In person