Compliance Officer, Management

Job Duties

• Compliance Officer's primary responsibility is design, implementation and effective operation of the compliance program.
• In carrying out policies and responsibilities of the office, Compliance Officer: have direct access to CEO and Board of Trustees; not be subordinate to financial business office director/manager; have authority to investigate compliance violations and act as needed; have access to all needed information, including contracts, billing records and contractual arrangements;
  Board of Trustees will provide oversight of Compliance Officer's activities; provides updates on a regular basis to CEO and Board of Trustees on progress of implementation and improvement of the compliance program.

• Oversee and monitor design, implementation and improvement of the compliance program in light of changes in regulatory and legal environment and conformity to ethical standards.
• Be responsible for developing, coordinating and participating in a multifaceted compliance education and training program that ensures all employees and affiliated parties are educated about Code of Conduct, corporate compliance program and other specific issues deemed necessary.
• Ensure independent contractors and agents who furnish services are aware of requirements of the compliance program with respect to coding, billing and marketing, among other things.
• Coordinate personnel issues with Human Resources to ensure List of Excluded Individuals and Entities, General Services Administration Debarment List and National Practitioner Data Bank have been checked with respect to all employees, medical staff and independent contractors.
• Work with CFO in periodic reviews, ongoing monitoring and evaluation of regulatory compliance in all business activities, and recommend development of internal systems and controls to reinforce compliance in those areas.
• Independently investigate and act on matters related to compliance, ensuring corrective actions are taken where compliance failures have been identified.
• Develop and manage Hotline system and other feedback mechanisms that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.
• Be responsible, together with Audit and Monitoring Committee, to implement all necessary actions to ensure achievement of objectives of an effective compliance program by means of review, relevant training, system of consistent enforcement of rules and development/implementation of corrective action plans.
• Work with Board of Trustees in consultation with outside legal counsel in reviewing and updating Code of Conduct to ensure its continuing currency and relevance in providing guidance to management and employees.
• Develop, maintain and revise compliance policies and procedures for general operation of the program and related activities to prevent illegal, unethical or improper conduct. Revise/update as needed.
• Oversee and manage performance of the compliance program and identify potential areas of compliance vulnerability and risk and provide specific direction for resolution of problematic issues, as well as general guidance on how to deal with similar situations.
• Prepare periodic reports and evidence for Board of Trustees on progress and effectiveness of compliance activities and efforts.
• Develop and oversee a system for uniform responses to violations of rules, regulations, policies, procedures and Code of Conduct and ensure proper reporting of potential violations of law to duly authorized law enforcement agencies.
• Establish audit controls and measurements to ensure correct processes are in place.
• Maintain a working knowledge of relevant issues, laws and regulation through periodicals, seminars, training programs and peer contact.
• Respond appropriately if a violation is uncovered, including direct report to Board of Trustees or external agency, if deemed necessary.
• As part of ongoing auditing and monitoring, Compliance Officer arranges for periodic independent evaluation of effectiveness of the compliance program.
• Performance of other duties as may be assigned from time to time.

The Hospital will train Compliance Officer on all…