Florida Hospice & Palliative Care Association

The St. Francis Reflections Director of Compliance is responsible for the organizational Compliance Program that incorporates the 7 elements of compliance. Under the general direction of the CEO, the Director of Compliance is responsible for the maintenance and implementation of the compliance program across the organization. Position will serve as the appointed HIPAA Privacy Officer. The Compliance Director will report directly to the CEO and the Board of Directors. A thorough knowledge of compliance and privacy principles with applicable laws, regulations, CMS Conditions of Participation, and SFR policies and standards is required.  This positions models and enforces a high level of ethics and standards of work place behavior.

REPORTS TO:                                          

CEO/Board of Directors                      

EDUCATION, TRAINING AND EXPERIENCE REQUIRED:

College education (Bachelor’s Degree. Master’s degree preferred.) and/or 5 or more years’ experience in Health Care Compliance, Contract Management, Law and HIPAA Privacy.  Experience in Hospice, EMR’s and Compliance Auditing.

CERTIFICATIONS/LICENSES REQUIRED: 

Certification in Health Care Compliance (CHC) required. Unrestricted State of Florida Driver License.  RN preferred.

SPECIFIC SKILLS AND ABILITIES REQUIRED:

Five years’ experience in a healthcare organization and minimum of 3 years in hospice to include demonstrated leadership. Past experience auditing and medical record review, HIPAA privacy, external audit processes. Possess strong analytical skills and knowledge of contract management.

PHYSICAL REQUIREMENTS:

Ability to lift, push, pull twenty five (25) pounds without difficulty; acute eyesight and hearing.  Able to work in under various work environments and with the with the stress of meeting deadlines.

PRIMARY RESPONSIBILITIES:

• Develops and Implements the Compliance Work plan that reflects the institution’s risks.
• Develops and Educates staff on the SFR Code of Conduct.
• Investigates allegations of reported compliance concerns in partnership with Human Resources and Clinical departments as needed.
• Manages the Compliance Reporting Hotline.
• Serves as the HIPAA Privacy Officer and implements the HIPAA Privacy program for the Organization.
• Periodically revising the Compliance Program in light of changes in the needs of the organization, and in the law and policies and procedures of government and private payer health plans.
• Conducts Board and Management Compliance Training.
• Prepares Board Compliance Reports.
• Identifies Organizational Risk Areas.
• Develops, coordinates, and participates in a multifaceted educational and training program that focuses on the elements of compliance program, and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards.
• Provides regular review and updates for management on the status of audits.
• Monitors regulatory awareness of compliance changes and issues and ensures the Board and management are aware of changes.
• Oversees an internal auditing program; coordinates and conducts internal auditing and monitoring activities.
• In conjunction with senior management, responds to administrative inquiries related to compliance issues or audits. Serves the individual responsible to respond to requests for clinical records from governmental bodies.
• Working with the education department, develops an appropriate effective training program for new employees and ongoing training for all employees.
• Oversees the Exclusion Database review process for volunteers, employees and vendors.
• Monitors external audit processes and maintains awareness of compliance issues.
• Manages external audits and completes timely responses.
• Develops and maintains compliance policies and procedures to meet current laws and regulations.
• Maintains current knowledge of regulations, laws and policies governing the institutions operations.
• In collaboration with the Quality program manager, oversees the implementation of the organizations QAPI
• Acts as the liaison with legal counsel for SFR and as directed by the CEO and/or Board
• In collaboration with senior clinical management, manages the CHAP Accreditation process.
• Completes timely revalidation with CMS, Palmetto, Medicaid and other entities.
• Completes regulatory reporting as required.
• Other duties as assigned.

COMPLIANCE:

Exhibits knowledge of organizational policies, and state and federal laws and regulations consistent with duties and responsibilities. Demonstrates high ethical standards and compliance with organizational standards.

QUALITY:

Actively participates in the Quality Assessment Performance Improvement program by identifying opportunities for improvement and by participating in performance improvement activities. Demonstrates the ability to apply customer service techniques to facilitate improved outcomes with internal and external customers.