Job Description

QUALIFICATIONS/CREDENTIALS: Education, training and experience that demonstrate possession of the knowledge and ability to perform the tasks listed below. The formal education or equivalent experience that would normally be acquired through the attainment of a bachelor’s degree from an accredited college or university. A minimum of two (2) years professional experience in the areas of corporate risk management and compliance. Prior participation in third-party audit reviews is desirable. Expertise in health care risk management, compliance, and quality assurance is highly preferred.

JOB DUTIES AND RESPONSIBILITIES:

Assures a work environment for all staff that is compliant with all relevant federal, state, and local laws and regulations, as well as corporate policies and procedures. Puts in place policies, processes and education that assures a professional environment that is free of harassment and allows all staff to function at their highest potential while safely caring for the needs of our residents.

Coordinates and implements system-wide programs, policies, and procedures to ensure system compliance with applicable federal, state, and local laws and regulations.

Develops and monitors written policies and procedures that establish corporate standards for compliance and risk management, giving specific guidance to management, professional staff, and individual departments as appropriate.

Conducts internal audits for departments and serves as liaison with external auditors from federal, state, and local regulatory agencies.

Chairs and participates in quarterly Risk, Safety, and Quality Management meetings and Quality Improvement meetings. Is responsible for generating data and trending reports for RSQM and QI meetings. Directs the Compliance Committee and provides leadership to staff in the performance of corporate compliance functions.

Develops and manages a communication tracking process for compliance and risk management programs and other projects at the direction of the Executive Director or the committees listed above.

Develops, implements, and maintains a system for confidential reporting, investigation and response to compliance or risk concerns. Includes coordination of a reporting system allowing for anonymous reporting.

Coordinates with legal counsel, as needed, in response to identified compliance or risk questions, concerns, or federal/state inquires or investigations.

Develops and directs communication with staff regarding current and relevant updates to compliance and risk programs, including written materials and training programs designed specifically to promote understanding of compliance and risk issues, laws and regulations, and consequences of non-compliance.

In coordination with internal and external legal consultants and other resources; maintains awareness of laws and regulations, keeping abreast of changes that affect health care systems.

Maintains a consistent management reporting process that provides the Executive Director with timely and relevant information on all aspects of compliance and risk issues.

Reviews and develops appropriate actions to issues, concerns, or questions relative to compliance and risk matters. Provides consultative leadership and support to staff and management as appropriate. Works in close coordination with the Director of Human Resources on relevant issues.

Coordinates the development, implementation, and maintenance of internal audit controls, measurements of performance, and reporting in the areas of compliance and risk; ensuring correct processes are in place for accurate and complete measurement and tracking of the performance of the risk and compliance programs across the system.

In coordination with the committees listed above, revises the compliance and risk programs to improve their effectiveness and response to changing organizational needs or relevant new or revised regulations, policies, and guidelines.

Assists in and coordinates corporate responses to compliance and risk reviews during licensing, relicensing and accreditation processes.

Manage any internal and external compliance and risk investigations, along with appropriate departmental leaders. Coordinates any needed staff interventions with the Director of Human Resources and the Executive Director.

Responsible for developing, submitting, and implementing regulatory, accreditation and other needed corrective action plans. Responsible for monitoring and assuring ongoing compliance with all relevant corrective action plans.

Directs efforts to ensure a safe work environment for staff and residents. In coordination with the Director of Human resources, develops initiatives to reduce worker’s compensation risk and liabilities.

Develops and monitors processes to minimize risk and reduce overall liability for facility.

Effectively communicate with all staff to ensure compliance and minimize risk.

Ability to facilitate, communicate, and train staff on proper processes and procedures.

Strong skills in the areas of process analytics, measurement and change. Ability to observe, analyze, plan, coordinate and implement needed processes change.

Maintain an awareness of facility and staff compliance and risk concerns and opportunities.

Maintains current and up-to-date knowledge of relevant risk and compliance issues, laws and regulations.

Able to work independently and without supervision.

Understands when additional expertise is needed and seeks assistance.

Is aware of and follows all safety regulations.

Complies with all facility policies and procedures.

Reports any suspected abuse, neglect and exploitation in accordance with all relevant laws, guidelines and regulations, as well as facility policies and procedures.

Meet all training requirements, background checks and health screening requirements.

Performs other duties as assigned.