Description

Under the general supervision of the Director of Quality & Patient Safety, the Compliance Coordinator is responsible for the organization-wide healthcare compliance program, including appropriate policies and procedures to promote compliance with applicable laws, regulations, and other governmental requirements. This individual provides advice as requested to the hospital’s leadership team and other organization staff as a resource and content expert in the areas of corporate compliance, ethics, regulatory affairs, and related topics. The Compliance Coordinator orients new managers/directors on their role and responsibilities regarding the hospital’s Ethics and Compliance programs. This individual collaborates with Administration on monitoring and managing Provider contracts and collaborates with Department Leadership on monitoring review of vendor contracts as requested and required to meet compliance standards. The Compliance Coordinator also assists with conducting investigations resulting from internal referrals and corporate compliance hotline calls. 

Principal Clinical/Technical Duties

Category: Corporate Compliance

o   Serves as the hospital's corporate compliance officer, overseeing the ongoing implementation and review of the hospital's corporate compliance program.

o   Monitors for compliance management issues, conducts compliance reviews when necessary, and assists staff with investigation of compliance issues.

o   Prepares formal and informal responses to governmental and other regulatory agencies’ investigations, inquiries, and requests, with guidance from hospital executive management, hospital legal counsel, and supervisor, as appropriate.

o   Ensures that all required elements of a compliance program are addressed.

o   Develop policies and procedures to establish guidelines for the organization, based on compliance program guidelines.

o   Communicates compliance standards to employees, physicians, business partners, and contract personnel.

o   Orients new managers/directors on their role and responsibilities regarding the hospital ethics and compliance programs.

o   Coordinates and monitors compliance training requirements for employees, including but not limited to code of conduct training, EMTALA, and other regulatory requirements.

o   Collaborates with Administration on monitoring and managing Provider contracts and collaborates with Department Leadership on monitoring and review of vendor contracts as requested and required to meet compliance standards.

o   Monitors and investigates compliance referrals from the corporate compliance hotline or other internal referrals.

o   Ensures that confidentiality is provided by the compliance program.

o   Coordinates with the hospital risk manager regarding compliance referrals, concerns, and potentially compensable events.

o   Communicates with the hospital's legal counsel as appropriate.

Category: Licensure & Accreditation

o   Assists the Quality Department with activities related to hospital licensure and accreditation

o   Maintains current knowledge of applicable law, standards, and regulations

o   In conjunction with the Clinical Risk Management Coordinator, serves as a liaison to external regulatory agencies for compliance with Federal, State, and other regulatory requirements.

Category: Hospital Committees

o   Chairs the Corporate Compliance Committee and coordinates the hospital Ethics Committee.

o   Serves as a member of the following hospital’s Committees:

• Corporate Compliance
• Ethics Committee
• Quality Council
• Other committees or workgroups as directed

Category: Other Duties

o   Other duties as assigned.

Requirements

Required Qualifications

Must be at least 18 years of age.
Bachelor’s degree or higher from an accredited institution with a major field of study in clinical health care, Health Care Administration, Business Administration, Accounting, Finance or related field. Must provide proof of the highest level of education obtained.
Working knowledge of corporate compliance programs and healthcare laws and regulations.
2 years of regulatory compliance experience required, acute health care preferred.
Ability to analyze issues and recommend solutions.
Ability to establish effective working relationships with others, including the medical staff.
Ability to effectively communicate in oral and written form.
Must have a well-groomed, professional appearance.
Must have the mental and physical ability to perform, with or without reasonable accommodation, the essential functions of the job.
Ability to lift, carry, pull, & push 50 pounds.
Language proficiency in English, with excellent written and verbal fluency. 

Preferred Qualifications

Clinical healthcare experience preferred.
Three to five (3-5) years of experience in hospital healthcare and leadership positions.
Experience in writing, reviewing, and maintaining healthcare contracts.
Working experience and knowledge of applicable sections of the Arizona Revised Statutes and Arizona Administrative Code, Centers for Medicare and Medicaid Services (CMS) regulations, Stark Law regulations, Anti-kickback and Safe Harbor regulations, Fair Market Value, and other applicable healthcare regulations.
Certified in Healthcare Compliance (CHC), Certified Compliance and Ethics Professional (CCEP), Certified Professional in Healthcare Risk Management (CPHRM), or Certified Professional in Healthcare Quality (CPHQ), current or obtained within two (2) years.
Previous Meditech experience or other related electronic records systems.