Director Compliance And Risk Management

Profile

Director, Compliance and Risk Management
Responsibilities: Manages day-to-day operations of the Compliance and Risk Management department including directly supervising Compliance and Risk Management Department staff. Leads and supports ongoing development, refinement, implementation, measurement, ongoing improvement and effectiveness of TVHC’s Compliance and Risk Management Plan. Documents and provides regular reporting to the CEO and Board of Directors (BOD) on the status of Compliance and Risk Management Program. Develops and implements a written plan that describes the Compliance and Risk Management Program. Writes, implements, maintains, and revises policies and procedures for the general operation of the Compliance and Risk Management Program and its related activities to prevent illegal, unethical or improper conduct. Reviews other organizational policies. Plans, coordinates, and provides guidance for the integrated functions of organizational strategic and risk management assessment and improvement, patient and staff safety. Utilizes project management methodologies, supporting the development and implementation of compliance assessment/process improvement and redesign. Leads and participates on teams that identify the best-known compliance and operational practices to achieve and retain optimal outcomes. Ensures that all 330 HRSA guidelines are adhered to on an ongoing basis as well as other key regulatory agencies. Leads and guides the HRSA Operational Site Visit, with the support of the Human Resources Director, Director of Accounting and with the Sr. Director of Population Health and Quality. Provides technical information in an equitable and consistent manner for staff, management, and Board of Directors concerning practice regulations, laws and standards, along with other related matters; provides guidance, direction, and training, as applicable, or makes recommendations for effective correction of performance issues from a corporate compliance stand point. Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Conduct investigative action and correction initiatives for all compliance issues. Follows through with all investigative procedures to resolution of the final outcome, developing and overseeing a system for uniform handling of such violations. Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required. Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline (Lighthouse); (b) heightened awareness of Standards of Conduct and HIPAA rules, and (c) understanding of new and existing compliance issues and related policies and procedures. Oversees compliance with, and completes application for the FTCA redeeming process and program requirements. Assists the CEO with monthly meetings, collaborates with management and staff to identify and support implementation of risk management, quality and compliance monitoring, and review audits as required by Health Resources and Services Agency (HRSA), 340B program and other regulatory agencies. Oversees policy distribution to operational owners and revision tracking, including compilation of a monthly Board report of policies to be approved. Create and send a quarterly summary of all approved policies to “All Staff.” This person will also be responsible for assuring maintenance of compliance and risk management intranet resources. Interprets regulations, standards and laws, educates, investigates, drafts policies, builds a business case for necessary changes, researches and presents best practices, leads projects to reduce barriers to care and mitigate problems and liabilities. Works with the Operations Department on Emergency Preparedness. Serves as a resource for all external and internal compliance and risk management audits; ensures that corrective action plans are documented in a timely manner and effectively implemented. Collaborates with the Chief Medical Officer (CMO) in the investigation of clinical events including adverse events, adverse event near misses, and significant adverse events; leads and/or participates in the development of root cause analyses as directed by the CMO. 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. May participate as consultant for employee disciplinary matters involving policy violations as needed. Works with the Director of IT on maintaining communication and staying abreast of HIPAA security assessment and incident reports. Acts as an independent review and evaluation body to ensure that compliance issues and concerns within the organization are being appropriately evaluated, investigated and resolved. Performs all duties in accordance with Service Excellence Standards. Assumes other duties, including special projects, as assigned or needed.

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