Compliance Officer Position
The compliance officer provides direction and oversight of the compliance program.
The compliance officer is responsible for identifying and assessing areas of compliance risk for the hospital; communicating the importance of the compliance program to the executive management and the board of directors; preparing and distributing the written code of conduct; setting forth the ethical principles and policies that are the basis of the compliance program; developing and implementing education programs addressing compliance and the code of conduct; implementing a retaliation-free internal reporting process, including an anonymous telephone reporting system; and collaborating with executive management to effectively incorporate the compliance program within system operations and programs and to carry out the responsibilities of the position.
Primary Job Duties and Responsibilities
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Ensuring that the compliance program effectively prevents and/or detects violation of law, regulations, organization policies, or the code of conduct.
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Regularly reviewing the compliance program and recommending appropriate revisions and modifications, including advising administrative leadership and the board of directors of potential compliance risk areas.
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Coordinating resources to ensure the ongoing effectiveness of the compliance program.
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Implementing and operating retaliation-free reporting channels, including an anonymous telephone reporting system available to all employees, volunteers, and affiliated providers.
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Developing educational programs for all employees, agents, affiliated providers, or others working with the hospital.
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Ensuring that the internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, agents, affiliated providers, or others working with the hospital.
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Ensuring that the system has effective mechanisms to reasonably determine that persons either promoted to or hired in management and certain other sensitive and/or responsible positions (to be designated) do not have a propensity to violate federal or state laws and regulations or engage in improper or unethical conduct in their designated areas of responsibility.
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Providing input and/or direction to Human Resources policies and procedures and the performance appraisal and incentive programs to ensure that improper conduct is discouraged and that support of any conformity with the compliance program is part of any performance evaluation process for all employees.
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Coordinating as appropriate with outside legal counsel, conducting or authorizing, and overseeing investigations of matters that merit investigation under the compliance program.
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Overseeing follow-up and, as applicable, resolution to investigations and other issues generated by the compliance program, including development of corrective action plans, as needed.
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Tracking all issues referred to the compliance office.
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Developing productive working relationships with all levels of management.
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Presenting periodic and annual reports on the compliance program to the board of directors.
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Developing and implementing, with approval of executive management and the board, an annual review of an update to the compliance plan.
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Reporting on a regular basis to the compliance committee on matters involving the compliance program. Additionally, the compliance officer at their discretion is expected to regularly report issues to the CEO and board of directors.
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Working with administrative leadership to provide adequate information to staff to ensure that they have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner.
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Ensuring that all contracts contain corporate-compliant language.
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Representing the compliance committee, including developing appropriate agendas, reports, and information as directed from by the committee.
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Performing other duties as assigned by the CEO.