The Compliance Officer (CO) oversees the Bristol Bay Area Health Corporation’s (BBAHC) Compliance Program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the BBAHC organization. The position ensures the Board of Directors, management and employees are in compliance with the rules and regulations of regulatory agencies, that corporate policies and procedures are being followed, and that behavior in the organization meets the corporation’s Code of Conduct. The CO also promotes an awareness and understanding of ethical principals consistent with BBAHC’s Mission, Vision and Values.
The CO needs to be a person of high integrity, and any other duties the CO has should not be in conflict with the compliance goals. The CO is highly placed in the organization so that he or she can exercise independent judgment without fear of reprisal, and so that employees will know that bringing a problem to the CO’s attention is not a wasted exercise or have fear of retaliation.
The CO acts as staff to the CEO and Board of Directors’ Corporate Compliance Committee by monitoring and reporting results of the compliance/ethics efforts of the company and in providing guidance for the Board and senior management team on matters relating to compliance. The CO, together with the Corporate Compliance Committee, is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program.
Must possess knowledge of specific laws and regulations imposed on healthcare systems by various agencies. (FTCA, Stark, Anti-Kickback, HIPAA, EMTALA, Federal Sentencing Guidelines, etc.)
Must be a RN or JD with a minimum of five years hospital experience and at least two years in corporate compliance.
Knowledge of analysis of data to identify patterns and trends is necessary.
Communication skills, both written and oral, with knowledge of medical terminology is necessary.
Prior IHS/PHS or Federal hospital experience and/or rural hospital experience is desirable.
Knowledge of The Joint Commission standards is preferred.
Requires a Bachelors degree. Prefer BS or Masters in Nursing; or a Masters Degree in health, administration, or business; a Medical Degree
Past experience in Risk Management and/or Performance Improvement is preferred
Certification in Healthcare or Corporate Compliance (CHC or CCEP) is preferred
Assists the President/CEO with the development and implementation of system-wide programs, policies and procedures to ensure compliance, taking appropriate steps to improve it’s effectiveness in light of changes to federal and state laws, the needs of the organization, agency regulations, and private payer health plans.
Prepares quarterly reports to the Board of Directors and the President/CEO detailing compliance issues and initiatives.
Establishes and provides direction and management of the BBAHC compliance hotline, a confidential system for employees and others to seek guidance on business conduct issues and to report suspected violations of law and/or the hospital policies and procedures without fear of retaliation.
Conducting or authorizing and overseeing investigations and making recommendations as to whether such investigations should be done internally or externally, depending upon the issue(s) involved and available resources. Coordinating as appropriate with general counsel.
Coordinating risk assessment and monitoring activities, including periodic reviews of departments. Contracts for outside auditors as approved by the President/CEO.
Overseeing follow-up and resolution to investigations, and other issues identified by the Compliance Program, including development of corrective action plans with all BBAHC departments, providers, agents and, if appropriate, independent contractors.
Ensures proper hospital reporting of violations or potential violations to duly authorized enforcement agencies as required and responding to government investigations and queries as the principal point of contact.
Periodically reviews and updates the Code of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
Institutes and maintains an effective compliance communication program for the organization, including training that promotes (a) use of the compliance hotline, (b) heightened awareness of BBAHC’s code of conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.
Serves as primary advisor to the President/CEO relative to all aspects of the BBAHC Performance Improvement program; including planning, designing and/or evaluating the principal program elements of Performance Improvement and Risk Management.
Oversees the Customer Comment and Risk Management Event tracking programs.
Oversees preparation for Joint Commission surveys and the development of responses to and corrective actions for identified deficiencies.
Oversees Utilization Review functions.