Northern Light Health
Position is located: Acadia Hospital
Work Type: Full Time
FTE: 1.0 (40 hours per week)
Work Schedule: 8:00 AM to 4:30 PM
Under the direction of the VP Compliance (VP Compliance), the Northern Light Acadia Hospital Compliance Officer (Acadia Compliance Officer) develops, implements, and maintains the Acadia Compliance Program to assure compliance with internal policies and procedures and all applicable federal and state health care laws and regulations, including HIPAA. The Acadia Compliance Officer promotes quality and provides service, assistance and guidance to Acadia Hospital staff on all manner of compliance and privacy-related matters; develops and reviews compliance policies and procedures; creates and implements compliance education; identifies potential areas of vulnerability and risk; and develops, implements and monitors corrective action plans to resolve instances of conduct that do not conform to Northern Light Health/Acadia policies or to federal or state laws or regulations. Serves as the Northern Light Acadia Hospital Privacy Officer. Serves as subject matter expert for The Joint Commission Standards and CMS's Conditions of Participation.
The Acadia Compliance Officer provides direction and leadership for the compliance program. Manages the implementation and ongoing effectiveness of compliance program activities. Coordinates compliance activities as directed by the VP Compliance, the facility Board of Trustees and the President. Promotes an awareness and understanding of positive ethical and moral principles consistent with the mission and values. Responsible for ensuring that the specific goals and objectives of the compliance program are both consistent with the standards of Northern Light Health/Acadia and are carried out effectively. Oversees the ongoing activities related to the development, implementation, maintenance and adherence to the organization's policies and procedures. Provides regular reports to the Board of Trustee Governance Committee.
This position involves matrix reporting to the President of Acadia Hospital.
Required Minimum Knowledge, Skills and Abilities
- Excellent communication skills, both verbal and written.
- Strong communication and leadership skills are essential. Must effectively present to large and small audiences.
- Strong analytical skills. Attention to every detail.
- Highest degree of credibility, integrity and discretion.
- Comfortable working independently and able to effectively manage large, complex projects through their entire life cycle with minimal supervision.
- Thrives on wide variety of intellectually challenging work.
- Comfortable assessing complex facts that may not lead to a black or white answer.
- Proficiency with Microsoft Office applications such as Word and Excel.
- Serves as a role model for compliant behavior consistent with the Northern Light Health/Acadia Mission, Vision and Values.
- Excellent written and verbal communication skills.
- Effectively presents to large and small audiences.
- Builds and maintains credibility and collaborative working relationships with compliance clients, including at the home office and other members.
- Handles deadlines and multiple projects.
- Publicizes and maintains a reporting system whereby employees can report compliance issues and concerns without fear of retaliation.
- Responds to requests for evaluation of issues from employees within the facility.Acts as a facilitator for the investigation and subsequent resolution of any issues.Follows established protocols for all investigation activities.
- Completes necessary continuing education to maintain professional licenses/certifications.
- Keeps current with emerging compliance risk areas and recommends new and/or changes to appropriate policies and procedures.
- Serves as an internal authority on relevant compliance laws and regulations, including developments that may affect Northern Light Health/Acadia.
- Seeks out relevant educational opportunities.
- Obtains relevant certifications.
- Proficient in use of HIPAA Disclosure Tracking Database and Compliance Activity and Event Manager (CARS).
- Responsible for ensuring Acadia compliance with HIPAA privacy regulations and Maine privacy laws.
- Provides leadership and oversight for all privacy-related activities for Acadia.
- Works closely with Information Security Officer on HIPAA security issues.
- Performs ongoing risk assessments and audits to ensure HIPAA compliance.
- Conducts periodic compliance risk assessments testing compliance with established laws, regulations and Northern Light Health/Acadia policies.
- Assists with the development, implementation, and maintenance of a comprehensive system-wide audit & compliance plan that ensures compliance with all Federal & State regulatory requirements.
- Monitors the performance of the compliance program and related activities on a continuing basis, taking appropriate steps to improve compliance effectiveness.
- Assists with the development, implementation, maintenance, and revision of compliance policies and procedures.
- Identifies potential regulatory compliance obligations.
- Documents all work performed.
- Maintains a log and file system in accordance with compliance program policies and procedures.
- Prioritizes investigatory activities in accordance with established guidelines and in accordance with direction of the VP Compliance.
- Works with human resources personnel to monitor and ensure the consistent enforcement of compliance violations through appropriate disciplinary action.
- Provides a quarterly status report of ongoing activities and investigations to the VP Compliance and the Acadia Board Governance Committee.
- Reviews conflict of interest disclosures and addresses any actual or potential conflict of interest pursuant to Northern Light Health policy.
- Develops an annual compliance work plan in collaboration with the Acadia President, Board members and Northern Light Health.
- Other duties as assigned.
- Identifies potential areas of compliance vulnerability and risk, develop and implement corrective action plans for resolution of problematic issues, and provides general guidance on how to ensure compliance on a consistent basis.
- Assists the VP Compliance with the institution and maintenance of an effective Northern Light Health Compliance Communication program, including promotion of the (a) use of the "Hotline", (b) heightened awareness of the organization Code of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.
- Assists with the development and implementation of the Northern Light Health compliance training program.Implements an effective general compliance training program for new employees and annual refresher training for existing employees.
- Assists with the implementation of organization-wide programs, policies and procedures to ensure compliance with applicable federal, state and local laws, rules and regulations.
- Member of Northern Light Health Compliance Task Force.Shares best practices in specific compliance program elements and implementation strategy.
- Chairs the Acadia Compliance Committee.
- In collaboration with the VP Compliance, develops and maintains a compliance audit plan for the facility based on an objective risk assessment.
- Conducts internal audits, reviews, and other investigations as part of a compliance audit plan of activities.Coordinates these activities with Northern Light Health Internal Audit.Documents all corrective action and reports these finding to the VP Compliance and local Compliance Committee no less than quarterly.
- Maintains a strong awareness of laws and regulations while keeping abreast of current changes that may affect healthcare systems or hospitals.Informs the employee population regarding these compliance matters through personal initiatives, seminars, training programs and peer contact.
- Serve as subject matter expert for The Joint Commission’s Standards and Elements of Performance as well as CMS’s Conditions of Participation, and facilitate readiness activities to maintain Acadia’s compliance with same.
- Submits accurate and timely travel reimbursement requests.
- Participates as an active member of Acadia’s leadership team.
Other Information :
Education and Experience
- Bachelor’s degree or an associate’s degree plus three or more years of health care compliance officer experience required.
- CHC/CHPC/CCEP strongly preferred. Will be expected to obtain healthcare compliance and privacy certifications within 12 months of start date.
- Familiarity with health care laws, regulations, and standards, including HIPAA.
- Understanding of coding and reimbursement systems and clinical experience preferred.
- Acute care hospital compliance officer experience strongly preferred.
- Thorough knowledge of hospital operations required.
Competencies and Skills
- Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed.
- Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
- Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
- Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.
- Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.
- Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately.
- Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
- Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
- Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
- Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others' actions and decisions with and without express authority.
- Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
- Required Bachelor's Degree
- Work with computers, typing, reading or writing.
- Prolonged periods of sitting.