DIRECTOR OF COMPLIANCE

GENERAL DUTIES & RESPONSIBILITIES:

1. Develop, initiate, maintain and revise policies and procedures for the general operations of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
2. Responsible for the communication, implementation, and maintenance of all compliance, accreditation, and regulatory issues pertaining to the operations of the health center.
3. Maintains a compliance program aimed at reducing risk for DotHouse Health.
4. Serves as the Safety Manager and the HIPAA Privacy Officer as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Consistently and promptly responds to specific questions and/or incidents regarding HIPAA compliance
5. Evaluate all aspects of DHHs Compliance Program including the HIPAA Regulations.
6. Coordinates and leads the monthly DHH Safety Committee meetings.
7. Creates and monitors privacy policies. Tracks all non-routine disclosure of Protected Health Information, complaints, questions, and allegations of non-compliance with the privacy program. Coordinates a follow-up response to all complaints, allegations, or questions.
8. Responsible for keeping knowledge current and monitoring changes to federal, state, and local laws/ regulations to ensure compliance by maintaining professional affiliations and participating in various professional activities.
9. Develops and maintains an expert working knowledge on Health Care compliance.
10. Coordinates with all staff members in preparation and planning for audits and surveys from regulatory agencies.
11. Coordinates tracers according to the Joint Commission standards to assess compliance and implement appropriate corrective actions with the Management Team or others as appropriate. Monitors subsequent compliance.
12. Communicate with the appropriate members of the Senior Leadership Team on a regular basis to ensure compliance with regulatory agencies on applicable areas that relate to their specific departments.
13. Reviews the Office of Inspector Generals (OIG) annual and semiannual work plan for relevance to DHH. Makes appropriate recommendations to the Chief Operating Officer.
14. Regularly reviews any communication from the OIG, Office of Civil Rights, or other third-party communications, such as the regular list serves provided to all Health care facilities.
15. Oversees the review of the OIG Excluded Individuals and Entities List of parties debarred from federal programs insuring they have been checked with respect to all new employees, contractors, and vendors and at regular intervals of current employees, medical staff, contractors, and vendors.
16. Maintains the confidential disclosure program ensuring timely follow-up to disclosures.
17. Implements and monitors the Health Centers Emergency Management Plan and Continuity of Operations Plan; in addition, other EP responsibilities with agencies such as Boston EMS, BMC, etc.
18. Monitors the RLDatix system and reviews all Incident Reports ensuring our safety and quality goals are achieved and that DHH is providing transparency to increase quality and accountability.
19. Monitors the Relias system to ensure all mandatory education requirements are assigned and completed in a timely and compliant manner.
20. Coordinates initiatives and special projects as assigned by the Chief Operating Officer and CEO.
21. Ensure a safe and healthy working environment for all staff.
22. Work with Human Resources to ensure compliance with all legal and regulatory occupational health requirements including, but not limited to OSHA, ADA, FMLA, DPH, HRSA, and CMS.

Education: Bachelors Degree required; Masters preferred

Certification/Licensure: Risk Management Certificate required.

Experience:

• Minimum of three (3) years experience in healthcare required.
• Minimum of two (2) years experience as a compliance officer, compliance manager, or related position.
• Excellent verbal, written, and interpersonal communication skills.
• Have excellent organizational skills
• Previous experience directly related to The Joint Commission and Corporate Compliance and other regulatory agencies as identified.
• Expert knowledge of OIGs Compliance Program
• Familiarity with Safety and Risk Management Software
• Prior experience in Regulatory Compliance interacting with federal, state, and local regulatory agencies
• Experience dealing with The Center for Medicare and Medicaid Services (CMS) and the Fiscal Intermediaries is strongly preferred