Director of Compliance

QUALIFICATIONS & EXPERIENCE

1. Bachelor's degree in healthcare, business, non-profit management, or related field.

1. 3-5 years of previous job-related experience preferred. Previous supervisory experience preferred.

1. Excellent facilitation skills

1. Demonstrated record of achieving and sustaining excellent project results

1. Experience providing education/training to staff preferred

1. Proficient in Microsoft Excel, PowerPoint, Word.

1. Experience in working with multi-disciplinary teams and moving projects forward.

1. Maintains a valid Michigan driver's license and has the availability of a reliable, licensed and insured vehicle for use on the job, vehicle must be insured in accordance with the State of Michigan.

1. Remains up-to-date on all routine immunizations required by LARA and agency policy.

SUMMARY OF JOB RESPONSIBILITIES

Responsible for directing and implementing the agency's compliance program in accordance with the mission and strategic goals of the agency, federal and state laws and regulations, and quality standards. Includes policy management, compliance training and education, effective communication channels, auditing and monitoring, investigations and corrective actions, and reporting. Supervises the medical records department. Designated as Compliance, Privacy, and Security Officer.

RESPONSIBILITIES AND DUTIES

Primary Duties

1. Ensures an effective compliance communication program for theagency, including promoting the use of the Compliance Hotline and awareness of the agency's Code of Conduct. Maintains working reporting mechanisms to enable employees, volunteers, or contractors to report any non-compliance without fear of retaliation.

1. Maintains up-to-date knowledge of laws and regulations. Regularly monitors changes to the Hospice regulatory landscape and researches their impact to ensure compliance with applicable state and federal laws, regulations and mandates. Monitors changes to other healthcare entities and analyzes potential impact to the agency. Participates in and represents Centrica Care Navigators at state and national level compliance-related committees.

1. Ensures effective coordination of the agency's responses to regulatory changes. Acts as a key resource to leadership and provides guidance in support of the agency's strategy for complying with all regulatory requirements related to clinical and non-clinical activities.

1. Develops compliance audit and monitoring tools. Manages internal compliance review and monitoring activities, communicating the review plan to relevant parties. Reviews any documents pertinent to the review such as policies and procedures, incident tracking reports, regulatory surveillance results, dashboards, contracts, business service agreements, and prior review results. Prepares reports synthesizing results and highlighting implications of findings. Collaborates with staff to develop action plans to identify and resolve the root cause of review findings and gaps. Monitors corrective action plans for resolution.

1. Identifies areas of compliance risk through audit and monitoring activities, hotline calls, and department reports. Assists with ensuring compliance with contractual requirements and federal and state government reporting and regulations.

1. Manages compliance-related processes including but not limited to policy/procedure review, exclusion screening, contract review, signature audit log, etc.

1. At the direction of Executive Leadership, oversees responses to external regulatory requests. Coordinates the preparation of documents and charts in response to outside inquiries from regulatory, licensing, and peer review bodies (e.g. Additional Development Requests (ADRs), medical records requests, CMS survey plans of correction, CMS 855A changes, etc.)

1. Promotes awareness of processes, internal controls, policies and compliance requirements. Updates the agency about issues and concerns, outcomes and systemic issues. Works with leadership throughout the agency to improve and integrate regulatory compliance into processes, systems, and employee awareness.

1. Initiates, co-leads, co-facilitates, and advises internal performance improvement teams, including the Board level Quality and Compliance Committee, the Internal QAPI Committee, and teams formed for focused performance improvement purposes.

1. Conducts ongoing compliance training and education. Tracks participation and reviews the effectiveness of training programs.

1. Provides leadership for the medical records functions and processes. Responsible for meeting the legal requirements for storage, retention and destruction of medical records.
2. In collaboration with Executive Leadership, develops and ensures execution of the Annual Compliance Plan.

1. Ensures that education and training on privacy and security is provided to all employees and volunteers.
2. Ensures policies are in place that protect against any reasonably anticipated threats or hazards to the security and integrity of protected information. This includes regular review of system activity to ensure compliance.

1. Implements security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level.

1. Conducts a risk analysis of potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information.

1. Ensures reporting mechanisms are available that enable employees, volunteers, or contractors to report any non-compliance without fear of retaliation.

1. Matters directly involving the CEO will be reported to the board representative and investigated under the direction of the board.
2. Ensures that information technology utilized by the agency supports and is consistent with security practices and security policies. Ensures all new purchases are consistent with security