Compliance Officer Position
The 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 which 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 his/her 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 language which is corporate compliant.
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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.
Principal duties
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Oversee, coordinate and monitor the day-to-day compliance activities of the business unit.
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In consultation with the corporate law department, establish a company compliance manual. Maintain and supplement the manual as necessary.
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Establish, supervise, and train teams of laboratory and department compliance officers responsible for identifying compliance issues at the laboratory/departmental level. Ensure appropriate communication for compliance issues between local and HQ levels.
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Develop and coordinate appropriate compliance training and education programs for all employees. Ensure and understand the company’s commitment to comply with all laws, regulations, company policies, and ethical requirements applicable to the conduct of the business. Assess the need for additional training and education and develop appropriate compliance programs.
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Develop, coordinate, and/or oversee internal and external audit procedures for the purpose of monitoring and detecting any misconduct or noncompliance. If any misconduct or noncompliance is detected, recommend a solution, and follow up to ensure that the recommendations have been implemented.
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Formalize and monitor a system to enable employees to report any noncompliance without fear of retribution, ensuring that the reporting system is adequately publicized and that allegations of noncompliance are investigated and responded to promptly.
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In consultation with the Human Resources Department, help ensure that there is a mechanism in place for disciplining instances of noncompliance (including the failure to prevent, detect, or report any noncompliance), appropriate to the nature and extent of the deviation, and ensure consistency in the application of disciplinary action.
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Work with the Human Resources Department to ensure a work force with high ethical standards, including the establishment of minimum standards for conducting appropriate background and reference checks on potential employees.
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In conjunction with the Corporate Law Department, interface and, when appropriate, negotiate with external regulatory agencies.
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Report to the Compliance Committee at its regular meetings, or as otherwise necessary, on any significant compliance issues to ensure appropriate discussion of such compliance issues and to ensure that appropriate action is taken.
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Carry out all duties and responsibilities as assigned by the Compliance Committee.
Job specifications—education and experience required
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Law degree preferred with experience in healthcare law and specific knowledge of fraud and abuse and Medicare/Medicaid issues.
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Auditing/CPA experience a plus.
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Experience in dealing with compliance issues preferred.
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Strong influencing skills and perseverance in investigating.
[Note: This job description was originally published in The Health Care Compliance Professional’s Manual, edited by R. Snell, B. Saunders. J. Murphy, E. Ryan; Aspen Health Law and Compliance Center; 1999. Aspen Publishers and HCCA. Gaithersburg, MD, and Philadelphia, PA. Reprinted with permission.]