TITLE: COMPLIANCE OFFICER
DEPARTMENT: ADMINISTRATION
SUPERVISOR: CHIEF OPERATIONS OFFICER
CLASSIFICATION: FULL-TIME, EXEMPT
POSITION SUMMARY: 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 Lake County Tribal Health is in compliance with the rules and regulations of regulatory agencies, that company policies and procedures are being followed, and that behavior in the organization meets the company’s Standards of Conduct. The Compliance Office exists: 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.
GENERAL PURPOSE: The Compliance Officer acts as staff to the Chief Executive Officer and the Chief Operations Officer by monitoring and reporting results of the compliance/ethics efforts of the company and in providing guidance for senior management team on matters relating to compliance. The Compliance Officer is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program.
ESSENTIAL JOB FUNCTIONS:  Develops and 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.  Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.  Collaborates with other departments (e.g., HIM, Medical, Employee Services, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the corporate attorney as needed to resolve difficult legal compliance issues.  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 of such violations.  Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated and resolved.  Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.  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.  Provides reports on a regular basis, and as directed or requested, to keep the Corporate Compliance Committee and senior management informed of the operation and progress of compliance efforts.  Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required. BOD Approved: 4/2022  Establishes and provides direction and management of the compliance Hotline.  Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.  Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.  Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness.
EDUCATION, EXPERIENCE, CERTIFICATIONS AND LICENSES:  Education: Bachelor’s degree in Health Care Administration, Public Administration, Business Administration or related field and a minimum of 4 years’ experience in a healthcare organization, to include demonstrated leadership. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations is a must.  Master’s degree preferred.  Must be able to work effectively with Native American People and other ethnicities in culturally diverse environments  Must possess a CA Driver’s license or if from out of state be eligible to obtain one within 2 months of employment  Must have a good driver’s record All LCTHC employees are expected to: -Provide the highest possible level of service to clients; -Promote teamwork and cooperative effort among employees; -Maintain safe practices; and -Abide by the LCTHC policies and procedures as they may from time to time be updated.
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. Sitting / Mobility: Approximately 70% of time is spent working at a desk. Balance of time (approximately 30%) is spent moving around work areas. Communication: Ability to effectively communicate with co-workers, Board members, members of outside agencies, in person, by telephone, and by email. Vision: Ability to effectively use a computer screen and interpret printed materials, memos, and other appropriate paperwork. Lifting / Carrying: Ability to occasionally lift and/or move objects weighing no more than 25 pounds. Stooping / Kneeling: Ability to access files/stock supplies in low cabinets and shelves. Reaching / Handling: Ability to input information into computer systems and retrieve and work with appropriate paperwork, equipment, and supplies. Use of standard office equipment, including computer, telephone, calculator, copiers, and fax. Work is performed in an office/clinic environment; continuous contact with other staff and the public.
INDIAN PREFERENCE: Preference may be given to qualified Native American Indians according to the Indian Preference Hiring Act, CFR 25 USC 472. Other than Indian Preference, Lake County Tribal Health Consortium, Inc. adheres to all provisions of the Equal Employment Opportunities Act. NOTICE OF DRUG-FREE WORKPLACE ACT REQUIREMENT: LCTHC is committed to maintaining a drug free and alcohol free workplace. LCTHC believes that a healthy, productive BOD Approved: 4/2022 workforce free from the effects of drugs is very important to all employees and patients. Substance abuse is incompatible with the health, safety, efficiency and the success of LCTHC. Employees who are under the influence compromise LCTHC’S interests, endanger their own and the health and safety of others and can cause a number of other work-related problems. As a condition of employment, each applicant receiving a job offer from LCTHC must take and pass a required drug screen test. HIPAA Health Insurance Portability and Accountability: This act was enacted to deal with three main areas with regard to patient information.  Security of health information  Standards of electronic transactions  Privacy of individually identifiable health information
IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change. Lake County Tribal Health is an At-Will Employer. Either the employee or LCTHC can terminate the employment at will, without advance notice, at any time, with or without cause