Position Title: Director of Compliance | Position Code: |
Department: | Division: |
Reports to (Position Title): | Effective Date: |
1. Quality Standard
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Under the general supervision of (CEO/governing board/board of directors):
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Develop, maintain, and support the implementation of the compliance program for [ORGANIZATION NAME].
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Facilitate the development of compliance programs for individual departments within [ORGANIZATION NAME], as needed.
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Coordinate and perform audits/reviews to prospectively test compliance with established laws, regulations, company policies and procedures, and managerial guidelines.
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Investigate reports of alleged noncompliance, as deemed necessary, to final resolution.
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Assist in the development of corrective action plans when areas of opportunity are identified.
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2. Essential Responsibilities
Planning Responsibilities
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Develop [ORGANIZATION NAME]’s compliance program, including, but not limited to, compliance-related:
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Policies and procedures
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Code of conduct
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Forms
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Guidelines
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Educational presentations
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Mechanisms for anonymous reporting of suspected violations
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Auditing and monitoring plans
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Corrective and disciplinary action plans
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Develop a compliance annual plan, including:
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Risk matrix identifying potential regulatory compliance obligations of [ORGANIZATION NAME] and prioritize areas for assessment
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Audit/review schedule delineating the areas identified for audit/review based on the strategic objectives established in the risk matrix
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Compliance department 90-day plan for other compliance activities (e.g., development of compliance-related programs, schedule of educational sessions, creation of compliance-related forms and postings).
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Develop [ORGANIZATION NAME]’s compliance department-specific compliance-related policies and procedures, forms, etc., as deemed necessary.
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Develop [ORGANIZATION NAME]’s compliance committee monthly agenda, and lead the monthly compliance committee meetings.
Organizing Responsibilities
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Develop detailed compliance audit/review schedules, to be updated on a quarterly basis, which are consistent with annual system risk matrix and plan.
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Coordinate compliance audit/review activity with audit activity of the external and internal auditors and other groups/individuals, as determined by the compliance officer.
Controlling Responsibilities
Operational and Educational Responsibilities
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Perform intra-departmental interviews with all key personnel involved with the process or function to verify compliance with established policies and procedures and applicable regulations, as deemed necessary.
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Prepare and analyze a narrative description of the process or function under audit/review in order to evaluate potential strengths and weaknesses and to determine the adequacy of the overall system to ensure compliance, as deemed necessary.
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Conduct or oversee compliance training and education, including formal training sessions to informal one-on-one instruction, as deemed necessary.
Audit/Review Responsibilities
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Perform or oversee performance of audits/reviews as delineated in the compliance audit/review schedule, and perform prospective audits/reviews in conjunction with other personnel as deemed necessary, especially where specific professional licensing is required and as determined by the CEO/chief operating officer/chief financial officer/board of directors.
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Develop compliance audit reports upon completion of each compliance audit/review, which detail recommendations designed to correct any potential weaknesses or areas of noncompliance discovered during the audit/review.
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Assist management of audit/review organizations/departments in developing opportunity for improvement action plans to correct potential weaknesses and to ensure ongoing compliance.
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Perform follow-up audits/review as generated by the compliance department, external auditors, agencies, etc. to ensure opportunity for improvement action plans have been adequately implemented.
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Assure that compliance audit/review reports are presented to the CEO, board of directors, and medical staff of the reviewed department/process, as directed by the compliance officer.
Investigation and Remediation Responsibilities
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Receive, document, and monitor reports of alleged noncompliance via the compliance hotline, or by other various means, to final resolution.
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Perform compliance interviews and investigate reports of alleged noncompliance to determine the validity, nature, and scope of the report in conjunction with the designated team members, as identified by the compliance officer.
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Develop compliance investigatory notes during the course of the investigation concerning reports of alleged noncompliance, as deemed necessary, while interfacing with the compliance officer and legal counsel, as necessary.
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Develop compliance investigatory summary reports during the course of the investigation and investigatory closure reports subsequent to the completion of the investigation involving reports of alleged noncompliance and under the auspices of the compliance officer and legal counsel, if deemed necessary.
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Assure that the investigatory summary reports and the investigatory closure reports are presented to the CEO and the board of directors as directed by the compliance officer.
Supervisory Responsibilities
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Supervise the compliance staff to assist in the implementation of the compliance audit/review program, compliance-related policies and procedures, risk matrix, and compliance 90-day plan.
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Supervise the compliance staff in conducting compliance intra-departmental interviews, narrative, and performing prospective audits/reviews, as delineated in the compliance audit/review schedule.
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Supervise the compliance coordinator’s and other compliance personnel’s audit/review work papers to ensure completeness and accuracy.
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Oversee the compliance staff to assist in receiving, documenting, and monitoring reports of alleged noncompliance (via the reporting telephone line and other various means) and tracking of other compliance monitoring areas (i.e., compliance education and training), as deemed necessary, to ensure ongoing compliance.
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Oversee the compliance staff in daily office functions, including various clerical activities.
Climate Setting and Leadership Responsibilities
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Create a working relationship with employees and management staff of all departments, clinics, and affiliated organizations, which allows for accomplishing the desired goals of the compliance program on a timely basis.
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Represent [ORGANIZATION NAME] to external parties, as necessary during the course of employment, so as to enhance the image of [ORGANIZATION NAME].
Operational/Technical Responsibilities
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Examine the effectiveness of established policies, standards, and procedures in assisting all levels of management in their obligation to comply with all applicable regulatory standards.
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Assist the management of affiliated organizations to develop educational plans, materials, and resources to educate employees in the overall objectives of the compliance program and specify substantive areas of compliance for their activity.
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Maintain a current understanding of regulatory trends and changes in law and advise appropriate management staff of trends affecting their activity.
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Abide by the standards of the department.