Statewide Director of Compliance

QUALIFICATIONS & EXPERIENCE

1. A minimum of a Bachelor's degree in a clinical and/or administrative field required. Master's degree preferred.
2. Minimum of five (5) years of experience in quality service improvement and regulatory compliance required.
3. Three (3) to five (5) years of previous management experience that entailed significant accountability for adherence to established legal and regulatory compliance requirements required.
4. Graduate of an accredited school of nursing with a current license to practice in the State of Michigan as a Registered Nurse required. Certification in hospice nursing (CHPN) preferred.
5. Healthcare compliance certification is required and should be in place upon hire or obtained within one (1) year of hire date.

SUMMARY OF JOB RESPONSIBILITIES

Responsible for overseeing the adherence to established legal and regulatory compliance and privacy statewide for the NorthStar Care Community (NSCC). Acts as a convener, facilitator, collaborator, and coach to develop and drive a culture that values legal and regulatory compliance in all aspects of the organization.

RESPONSIBILITIES AND DUTIES

Primary Duties

1. Ensures effective organizational strategic results are achieved, working collaboratively with others.
2. Continuously leads efforts and collaborates with direct reports, key stakeholders, all NSCC affiliates, and NSCC leadership to oversee and take action to prevent and respond to legal, regulatory, privacy, and medical record non-compliance. Ensures that the compliance program is implemented throughout the organization.
3. Oversees and participates in the development, maintenance, and continuous improvement of systems for auditing, monitoring, and tracking compliance program initiatives and compliance issues, and distributes results to appropriate staff as needed.
4. 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.
5. Monitors organization's compliance hotline and follows up on related hotline calls.
6. Acts as a liaison between internal leaders and surveyors in a consultative manner with onsite survey; participates in accreditation activities including creation and submission of corrective action plans.
7. As directed by the Associate Vice President (AVP) of Quality and Compliance, serves as a liaison with external auditors and participates in medical record requests and audit activity.
8. Collaborates with the AVP of Quality and Compliance in annual and ongoing risk analysis activities for potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information.
9. Serves as organizational Privacy Officer and follows up on internal and external HIPAA compliant patient record requests.
10. Works collaboratively with the Security Officer to provide leadership, direction, and response in ensuring compliance with HIPAA and related standards.
11. As directed by the AVP of Quality and Compliance, oversees and participates in the development, maintenance and distribution of policies and procedures for the organization.
12. Follows up on customer inquiries to ensure concerns are addressed in a timely manner.
13. Proactively keeps abreast of hospice and palliative care trends, best practices, and any anticipated legal and regulatory changes. Takes appropriate action to ensure a culture of excellence is maintained.
14. As directed by the AVP of Quality and Compliance, oversees licensure, including the 855A, certification, credentialing, and other regulatory applications and renewals, communicating and following up with regulatory authorities or health plans as required.
15. Proactively assesses, leads, participates, and promotes a culture of excellence and innovation at the employee, departmental and organizational levels, aimed at continually improving employee performance and engagement.
16. Maintains oversight for recruitment and retention efforts consistent with the organizations vision, mission and values which ensure the engagement and retention of staff, within the designated area of responsibility, in collaboration with Human Resources.
17. Proactively applies an inclusive management style and collaborates, as appropriate, with leaders, directors, and staff to ensure system linkage and integration.
18. Effectively establishes, leads, facilitates, and participates in meetings at the individual, group and organizational levels, both within and external to the organization, with ease and comfort to achieve desired outcomes.
19. Maintains oversight of all allocated resources within a designated region including but not limited to time, expenses, supplies and labor and ensures pre-determined financial margins and/or outcomes are achieved.
20. Maintains oversight of all employee compliance related performance outcomes within the State of Michigan and ensures that a culture of accountability and responsibility is fostered to achieve desired performance outcomes and staff competency.
21. Proactively works to coach and/or mentor direct reports and subordinates to improve performance. Ensures that appropriate corrective action and performance improvement plans are administered per organizational guidelines, when appropriate, in collaboration with Human Resources.
22. Ensures internal and external education, training and activities for self and staff to promote personal and professional growth and to ensure staff competency is maintained at all times.
23. Promotes NorthStar Care Community in all professional external and internal contacts. Proactively promotes census growth within designated region(s) and seeks to offer care that meets the unmet diverse needs of the community.
24. Models and promotes knowledge of palliative care and hospice philosophies and articulates and promotes the organization's vision, mission, and values locally, statewide, and nationally, when appropriate.
25. Proactively participates and collaborates externally, with various individuals and/or groups, to establish various benchmarks and standards as it pertains to hospice and palliative care, locally, statewide, and nationally, when appropriate.
26. Upholds the organizational Code of Conduct, policies and procedures and all regulatory and legal requirements.
27. Models the NorthStar standards to care for every person, every time, 100% of the time.