Director of Compliance

Job Description

Job Description

Description:

Position Summary:

Reporting to the Chief Operating Officer this position is responsible for developing and coordinating compliance programs that monitor operational and programmatic compliance. This position is for the development of clinical standards and training programs.

Primary Responsibilities:

1. Direct the development, implementation and evaluation of department goals, objectives, policies, procedures, and standards of practice; which contribute to the delivery of care.

1.1. Define, implement, and maintain program and operational indicators that support

monitor of program compliance.

1.2. Develop and implement tools to conduct effective program evaluation.

1.3. In concert with Chief Nursing Officer, Establish accreditation/regulatory preparation process and implement to ensure all

areas achieve successful accreditation.

1.4. Perform and coordinate performance audits to identify areas of concern and ensure

uniformity of practice standards.

1.5. Collaborate and coordinate with the Director of Quality Improvement to ensure regulatory

standards are met and maintained.

2. To coordinate, develop and present educational/training programs to maintain, enhance, and assess job performance and competencies of staff.

2.1. Develop and implement training curriculum, and training programs materials that promote educational events and presents programs based on employee and management request and assessments.

2.2. Conduct and arrange for educational training sessions in collaboration with HR.

2.3. Provide review of job description and competencies in conjunction with Human Resources for designated clinical staff.

2.4. Provide feedback regarding staff skills, reassessing specific needs, creating action plans and conducting or making provision for the affiliated health care agencies.

2.5. Assist all department chiefs with their respective audits.

3. Direct activities related to the development and maintenance of administrative and clinical policies and procedures.

3.1. Perform annual review and update of policies and procedures.

3.2. Serve on various internal and external committees.

3.3. Coordinate with the clinical leadership in the development of new procedures.

3.4. Act as a resource to the community, outreach programs and other health-care organizations.

3.5.Supervise and manage special project activities.

4. Serves as CSHC’s Risk Manager and Claims Point of Contact for HRSA:

4.1. Coordinates Risk Management Functions daily to maximally ensure that identification of risk exposure, assessment, appraisal and loss prevention are carried out so that the Health Center remains safe for its patients, families, employees. Identifies and limits legal exposures and directly assists outside counsel/Department of Justice AUSAs assigned to federal tort cases in the handling / defense of legal claims.

4.2. Responsible for the management and processing of all claims-related activities on a daily basis. This includes but is not limited to coordination of claims management, addressing any potential or actual health or health-related claim (including medical malpractice claims) that may be eligible for FTCA coverage as well as working with the Finance and People departments on other commercial liability and/or employment claims.

4.3. For any potential or actual claim:

· Responsible for ensuring the preservation of all CSHC’s documentation related to any actual or potential claim or complaint (including issuing, re-issuing and all education related to Litigation Holds).

· Responsible for ensuring that all FTCA-related notification of intent to sue or other service of process/summons that CSHC or its providers receive related to any alleged claim or complaint is promptly sent to the HHS Office of General Counsel General Law Division.

· Responsible for working in full cooperation with the HHS Office of General Counsel Law Division or if deemed covered, the Department of Justice attorneys that are assigned to defend.

5. Direct activities related to the development and maintenance of administrative and clinical policies and procedures.

5.1. Perform annual review and update of policies and procedures.

5.2. Serve as clinical liaison on various internal and external committees involved in

establishing policies and procedures.

5.3. Coordinate with the clinical leadership in the development of new procedures.

5.4. Act as a resource to the community, outreach programs and other health-care organizations.

5.5.Supervise and manage special project activities.

6. Other duties and/or other departments/locations as applies.

Requirements:

Qualifications & Skills:

· At least 5 years of experience in healthcare administration, preferably risk management Masters preferred.

· Experience with staff and program development.

· Knowledge of accreditation standards, federal guidelines, and health care organizational standards.

· Strong written and verbal communication skills.

Physical Requirements:

· Must be able to stand or sit for prolonged periods (at least 50% of the time)

· Ability to lift up to 25 pounds and load onto shelves

· Visual acuity sufficient for frequent reading and computer use

Benefits:

CSHC offers a generous benefits package including:

· Competitive Medical and Dental Insurance

· Employer-paid Life, Accidental Death & Dismemberment, and Long-Term Disability Insurance

· Retirement-403(b) plan

· Vacation, Holiday, Personal and Sick Time Accruals

· Flexible Spending Reimbursement Accounts (Health and Dependent Care)

· Educational Assistance and Tuition Reimbursement Programs

· Commuter Benefits

· Opportunities for academic appointment at Boston University / Boston Medical Center

Pay Range: $114,000.00 to $177,000.00 Annually. Compensation is commensurate with years of experience.