Job Summary and Description
The Senior Director of Compliance will have the primary responsibility for organizational compliance with regulatory standards as determined by federal, state and accrediting bodies while contributing to the strategic future of the organization. This position will serve as the subject matter expert (SME) to assure that compliance systems and processes are in place. This position also serves as a back up to the Deputy Chief of Standards and Compliance in the event of their absence.
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES
- Familiar with and promotes compliance with federal/state acts and regulations through policy development, guidance and educational programs. Including: Patient Privacy, Americans with Disability Act-ADA, CMS regulations, Health Insurance Portability and Accountability Act-HIPAA, National Practitioner Data Bank, Occupational Safety and Health Administration-OSHA, and Stark Law.
- Provides ongoing communication with the Corporate Compliance Officer and the Director of Information Security and Governance.
- Ensures a solid patient rights and advocacy/complaint/grievance program is maintained and managed with strong processes.
- Assists Corporate Compliance Officer and/or legal counsel in investigative efforts, risk assessments and procedural activities.
- Assists with business associate agreements with those required to access protected health information and coordinates contract review with the Corporate Compliance Officer.
- Demonstrates the ability to adhere to the professional code of ethics and the organization’s policies/procedures, to include confidentiality, patient rights, and continuing education.
- Demonstrates the ability to maintain a professional and productive work atmosphere by professional behavior, communicating in a manner that promotes cooperation and teamwork with internal and external stakeholders including but not limited to, facility staff, supervisors, patients and visitors.
- Ensures HIPAA Education.
- Ensures policies and procedures conform to CARF and Joint Commission, state specific licensing and specific payer requirements. Implements systems to ensure continue readiness, including planning for evolving/new standards updates annually.
- Self-monitoring activities/assessments are regularly scheduled using chart reviews, on-site inspections and audits.
- Facilitates preparation, implementation and on-going monitoring follow-up of regulatory/accreditation site visits.
Leadership and Staff Development
- Hires, trains, supervises, counsels, disciplines, and terminates assigned staff as appropriate
- Other duties as defined
This position supervises the Assistant Director of Compliance, which includes but is not limited to, providing leadership to the Compliance team to ensure essential job functions are maintained relating to special projects, day to day assignments and investigations.
MINIMUM EDUCATION & EXPERIENCE REQUIRED
- Master’s degree with five (5) years progressive healthcare experience
- Bachelor’s degree or higher in nursing or health related field with eight (8) years of experience in a senior leadership healthcare role.
SKILLS AND KNOWLEDGE REQUIRED
- Fundamental knowledge of statutory and regulatory requirements of health institutions
- Able to interface with members of a multidisciplinary team and provide timely information regarding patient behaviors and symptoms
- Experience and skill in communicating with impact to effectively engage others and achieve desired results.
- Experience and skill in handling multiple conflicting assignments, demands, and priorities with attention to detail. Additionally, experience and skill in developing ideas and solutions in response to clinical issues and barriers.
- Strong organizational, analytical, writing and verbal communication skills.
- Strong working knowledge of accreditation and licensure rules that apply to medical and behavioral health
- Ability to communicate and promote cooperation with the leadership team, staff, patients and their families to include the ability to project a favorable, professional image in the public.
- Ability to navigate diverse, voluminous work responsibilities and the corresponding pressures.
- Able to demonstrate understanding of mental illness/substance use disorder and associated symptomatology.
- Must have compassion and understand basic tenets of recovery
- Able to demonstrate basic computer skills, including use of EMR, Outlook, Excel and Word.
- Able to work as a team with other professionals and to carry out responsibilities with supervision
- Able to facilitate task driven work groups with key leadership accomplishing a common goal
- Able to follow CBI Chain of Command
COMPLEXITY AND SCOPE OF POSITION
- Able to understand and interface with people experiencing a behavioral health crisis and participate in a multidisciplinary treatment team approach to care. Ensures systems are in place which promotes patient safety and standard of care to patients of CBI. Must be able to multitask and maintain positive working relationships with other CBI team members, patients, and their families. Applies knowledge and skills to assist in problem solving to ensure a safe treatment milieu through policy that is regulation driven under the direction of a registered nurse or medical practitioner.
- All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills aptitudes and abilities to perform each duty proficiently.
- Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills or abilities.
Skills Necessary to Perform Assigned Tasks and ongoing performance that each individual will be measured against in addition to those noted above:
- Reading & Comprehension: Must have the ability to read and comprehend information without difficulty.
- Documentation: As evidenced by all work being completed by the end of scheduled shift and in adherence with A.A.C., ACOM, and Community Bridges established documentation standards in process and policy.
- Typing Skills: This position requires the specialist to type 30/wpm.
- Computer Skills: Familiar with Microsoft systems such as Outlook, Word, and Excel.
- Linguistic Ability: Demonstrates the ability to coherently communicate with others.
- Foreign Language: Not required for this position but is helpful and is strongly encourage.
- Analytical: Demonstrates an ability to synthesize complex information and report it to others in a calm and precise manner.
- Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of costumers or employees of organizations.
- Interpersonal Relations: Works well with others and can be depended upon to follow through with task completion and be available to assist.
- Chain of Command: Follows the established chain of command and does not create situations that would call into question the authority of supervisor or impede their ability to manage the facility or program.
- Ethics: Adheres to a principle of “Do no Harm” by demonstrating personal integrity in interactions with staff, patients, and public. This is also demonstrated by one’s ability to perform assigned duties in a competent manner without the violation of Community Bridges policies/processes, patient and/or employee rights, or violation of State, Federal, or local laws.
- Agility: Able to move around quickly and freely in response to crisis situations.
- Physical Abilities: Must be able to move and/or lift a minimum of 150lbs. Has the ability to assist patients with self- care needs such as bathing and getting up from ground and walking.
- Quality: Performs work neatly and completely. All work is completed within the time allowed for task per policy.
- Customer Service: Ensures that community stakeholders (police, fire, probation, businesses, clergy, insurance companies, providers, RBHA’s, concerned citizens, etc.) are treated with the utmost respect and assisted to the best of our ability in each case. Never saying “no” but always assisting each request within the context of the agency mission and purpose. Is evidenced by not receiving a community complaint or excelling in the area of customer service.
- Patient Care: The extent to which the employee promotes empathy, warmth, understanding, and treats each patient with respect and dignity always keeping in mind their cultural, psychological, medical, social, and humanistic needs.
- Assessment & Triage: Assessments are accurate as to the patient’s presenting issue while respecting the individual’s cultural, psychological, social, and medical status. Assessments are conducted within the timeframe and context identified in policy and process and is appropriate in their use for developing a plan of action for the seamless transition to the next appropriate level of care.
- Patient Care Planning: The extent that the designated (treatment, continuing care, health & wellness, discharge) plan developed by the employee is in conjunction with the goals of the patient as well as those areas identified in his or her associated assessment that require attention.
- Problem Solving: Identifies and resolves problems in a timely manner; Develops alternative solutions.
- Judgment: Displays willingness to make decisions; Exhibits sound and accurate judgment.
- Motivation: Sets and achieves challenging goals.
- Oral Communication: Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions.
- Written Communication: Writes clearly and informatively.
- Quality Management: Looks for ways to improve and promote quality.
- Organizational Support: Follows policies and procedures; Supports organization’s goals and values.
- Organization: Prioritizes and plans work activities; Uses time efficiently; sets goals and objectives.
- Professionalism: Approaches others in a tactful manner; treats others with respect and consideration regardless of their status or position.
- Safety and Security: Observes safety and security procedure; Reports potentially unsafe conditions.
- Quantity: Meets productivity standards.
- Adaptability: Adapts to changes in the work environment; changes approach or method to best fit the situation.
- Innovation: Displays original thinking and creativity; meets challenges with resourcefulness; Generates suggestions for improving work.
- Scope of Practice: The extent to which the individual remains focused on their professional skill and does not deviate into areas for which they have no training or expertise.
- Attendance: Remains alert and awake throughout the entirety of a scheduled shift. Schedules time off or other related absences within the time allotted by Community Bridges Policy and adheres to the policies around absenteeism.