The Compliance Officer reports administratively to the CEO of the hospital. The Compliance Officer has a direct reporting relationship to the Board of Trustees. This position is responsible for reporting any and all violations either through the Board Compliance Committee or directly to the Board of Trustees.
Duties, Tasks and Responsibilities (includes, but is not limited to):
- Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities.
- Manages day-to-day operation of the Compliance Program.
- 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 to direct compliance issues to appropriate existing channels of investigation and resolution.
- Consults with external legal counsel 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.
- Acts as an independent review and evaluation body to ensure that compliance issues/concerns within the organization are being appropriately evaluated, investigated and resolved.
- Develops an annual Work Plan for auditing and monitoring based open the OIG Work Plan for Board approval.
- 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.
- Chairs the Hospital Compliance Committee. Attends meetings of the Board Compliance Committee.
Bachelor’s Degree in related field Required.
CHC from Compliance Certification Board Required within 2 years of hire.
Compliance, preferably in a hospital setting minimum 2 years Preferred.