Kent Campus Hospital

STATUS: Full Time 80 Hours

SHIFT: Days

GENERAL SUMMARY:

Summary:
Manages the day-to-day operations of the Corporate Compliance Program to achieve high levels of compliance with all applicable laws and regulations while supporting the vision and mission of the organization. Coordinates compliance training, maintains compliance policies, monitors/reports results of compliance/ethics efforts, and provides guidance on matters related to Corporate Compliance. Manages the annual enterprise risk assessment. Oversees research compliance, including audit activities to ensure institutional compliance. Management of the Conflict of Interest program.

ESSENTIAL FUNCTIONS & ACCOUNTABILITIES:

1. Develops, initiates, maintains, and revises policies and procedures for the general operation of the Corporate Compliance Program and its related activities to prevent illegal, unethical or improper conduct.
2. Remains current on compliance issues and provides timely updates to policies to ensure continuing currency and relevance in providing guidance to management and employees.
3. Ensures the compliance program functions in accordance with all applicable laws, regulations, and accreditation requirements.
4. Provides compliance direction after analysis of existing operations and operational proposals for potential compliance issues.
5. Regularly provides guidance to corporate compliance team members and other staff as appropriate to ensure departmental direction is effectively executed.
6. Provides direction and oversight to all areas of operations of the Corporate Compliance Department.
7. Develops and administers the corporate compliance education and training program.
8. Creates compliance website content; routinely updates website content; identifies and posts online resources for institutional reference and use.
9. Manages and promotes the Corporate Compliance Alert line.
10. Manages the Conflicts of Interest Program and Chairs the Conflict of Interest Committee.
11. Remains current on Federal and State regulations and communicates to appropriate department leaders to ensure compliance within Regulatory Compliance, Research Compliance, and Auditing.
12. Collaborates with Federal and State Regulators such as, but not limited to, OCR, HHS, OIG, and CMS on. Compliance related matters. Conducts regular investigations / audits to ensure organization and/or department compliance with regulatory statutes.
13. Coordinates Compliance with the Exclusion Program in accordance with Office of Inspector General.
14. Involved in ongoing department projects.
15. Assists with the preparation of quarterly comprehensive written reports to the Board of Directors, Executive Compliance Committee as well as, maintenance of the compliance dashboard. Provide new Board member orientation.
16. All other duties as assigned, within the scope and range of job responsibilities.

REQUIRED MINIMUM EDUCATION AND CREDENTIAL:

• Education Bachelor Degree
  Bachelor Degree
  Master Degree
  Health Administration
  Related field
• Credential CHC within 12 months of hire if not already obtained

EXPERIENCE:

Required: 5 years of related compliance experience. Health care experience with medical record & medical terminology.

Preferred: Prior health care operations or clinical background

PREFERRED EDUCATION AND CREDENTIAL:

• Education
• Credential Certified in Healthcare Research Compliance
  Certified in Healthcare Privacy Compliance

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