Executive Director of Compliance & Support Services
- Job Title: Executive Director of Compliance & Support Services
- 557 W WASHINGTON ST
- Burns, OR, 97720
- Employee Type: Full-Time(Exempt)
- Required Degree: Four_Year_Degree
- Manage Others: Yes
- Name: Jen Hoke
- Phone: 541-573-8642
- Email: firstname.lastname@example.org
PURPOSE OF POSITION: The Executive Director of Compliance and Support Services reports to the Chief Executive Officer and is responsible for the development, implementation, oversight, and evaluation of all aspects of the HDH compliance program. Implements and administers programs, policies, and practices to ensure that organization complies with CMS Conditions of Participation, HIPAA, and accreditation standards. Monitors and administers compliance with the Department of Health and Human Services (DHHS) Office of Inspector General’s (OIG’s) Voluntary Guidelines for Hospital Compliance in 1998, the Supplemental Hospital Guidelines in 2005, Third-Party Medical Billing Companies in 1998, and other federal and state regulations. Submits reports to regulatory agencies as required.
ESSENTIAL JOB FUNCTIONS:
Acts as a liaison to government agencies and coordinates site visits for regulators. Investigates potential compliance violations and takes corrective action as necessary. Conducts investigations and audits to identify areas of risk, drafts plans for improving compliance practices to address those risks, and monitors to ensure the program is following best practices and standards. Sets up training programs to ensure all employees understand how to meet their compliance obligations. Serves as a member of the hospital administrative team and provides internal compliance consulting services on a broad range of projects in support of hospital programs and activities.
· Research and become expert in the compliance related laws, rules and regulations, and standards that HDH is subject to. Act as a resource to the organization on compliance, documentation and coding issues.
· Serve as an internal consultant and advisor to the Chief Executive Officer/Administrator and Board regarding compliance strategies and initiatives. Partner with other management team members to identify and facilitate compliance process improvements. Maintain awareness of changes in regulations, policies and overall trends that may affect hospital compliance.
· Oversee policies and procedures for HDH and ensure that they are reviewed and updated on a regular basis.
· Monitor changes to regulatory guidelines and requirements and coordinate the implementation of changes into daily program activities. Assist with implementation of action plans and process improvements.
· Lead the development, implementation and maintenance of the Healthcare Compliance Program for HDH. Develop and write policies and procedures that establish standards for compliance, giving specific guidance to management, operational leadership, and departments.
· Ensure continuous compliance with laws, regulations and standards. Collaborate with legal counsel, department and organizational leadership, to identify potential areas of compliance vulnerability and risk. Develop and implement corrective action plans for resolution of problematic issues, and hardwire processes to prevent future occurrences.
· Lead monitoring and review activities including conducting audits for compliance to regulatory guidelines.
· Implement and provide direction and management of a compliance Hotline.
· Respond to external audits and government investigations. This includes developing corrective action plans, securing approval and ensuring plans are implemented.
· Disseminate information and educate HDH employees regarding a broad spectrum of compliance related topics.
Oversee and monitor the effective performance of department managers. Collaborate with them on goals and strategic alignment with the organization providing support and accountability. Provide support and direction in personal development targets and regularly monitor performance and provide coaching for improvement and development. Take corrective action, up to and including separation from employment, after consultation with the Human Resource Manager, to address performance deficiencies.
Supervisory Responsibilities for nine employees are as follows: Manager Environmental Services, Manager Dietary Services, Manager Hospital Foundation, Manager Marketing and Public Relations, Manager Materials Management, Manager Facilities Services, Supervisor Safety and Security, and Outreach Coordinators (2).
Perform the Duties required of and Administrative team member (see description below)
Maintain professional, cooperative working relationship with hospital staff, physicians, care providers, patients, other organizations, and the public to provide quality customer service in a courteous manner.
Maintain work areas in a clean, orderly and secure manner.
MANDATORY REQUIREMENTS: Possession of a Bachelor’s degree in a related field. Minimum of five years healthcare compliance related experience (within compliance or as part of another high level role) and/or coding in a healthcare setting required, or any satisfactory combination of experience and training which demonstrates the knowledge, skills and abilities to perform the above duties.
LICENSE/CERTIFICATION: Certified Healthcare Compliance (CHC) required. Must obtain certification within 18 months from hire date if not obtained at time of hire.
DESIRABLE REQUIREMENTS: Executive management experience preferred. Clinical experience preferred.
KNOWLEDGE AND SKILLS:
· Strong interpersonal skills and evidence of previous success in dealing with staff at all levels, including nurses, non-physician practitioners, physicians, and management.
· Strong writing and presentation skills and ability to interact with all levels of leadership.
· Strong analytical, investigative and decision-making skills.
· Ability to maintain up-to-date knowledge of standards, laws, rules, regulations, and best practices in healthcare.
· Ability to maintain confidentiality and adhere to all HIPAA guidelines and regulations
· Knowledge of Medicare and Medicaid documentation and coding rules and guidelines.
· Knowledge of healthcare compliance audit methodologies, principles and techniques.
· Ability to interpret and apply documentation and coding rules and regulations, facility fee charge capture and reimbursement methodologies.
· A demonstrated commitment to integrity, regulatory compliance and ethical decision making.
· Demonstrated proactiveness and ability to work independently and self-directed in managing multiple concurrent projects.
· Advanced skills in all MS Office applications (Word, Excel, Outlook, and PowerPoint).
· Strong orientation to deadline and detail