Chief Compliance Officer/Privacy Officer

SUMMARY OF JOB:

Oversees the Compliance Program and provides leadership, direction and accountability related to compliance matters within the organization.  Assists the Board of Trustees, management, employees, medical staff and workforce to comply with federal, state and local statutes, regulations and ordinances as well as the organization’s policies and procedures and promotes ethical behavior in the organization consistent with the Compliance Program’s Code of Conduct.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. For all Colorado West Healthcare System entities, facilitates conformance with applicable legal and regulatory requirements, including but not limited to requirements relating to Medicare and Medicaid conditions of participation and reimbursement, referral source relationships, employment and discrimination law, environmental laws, etc.
   • Maintains current knowledge of the organization’s legal and regulatory requirements. and
   • Oversees all compliance and privacy investigations.
   • Oversees outside investigations by government and regulatory agencies. 
2. Develops, implements, administers, and evaluates standards, policies and procedures for the protection of system-wide health care privacy and confidentiality. Collaborates with the Security Officer to facilitate access of health care information as authorized by HIPAA, HITECH and other legal requirements, as well as organizational requirements.
    
3. Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct, and manages day-to-day operation of the Compliance Program.
    
4. Develops and periodically reviews and updates Code of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
    
5. Collaborates with other departments (e.g., Risk Management, Patient Accounting, Human Resources, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution.  Consults with outside counsel as needed to resolve difficult legal compliance issues.
    
6. Responds to alleged violations of statutes, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures.  Develops and oversees a system for uniform handling of such violations.
    
7. Reviews and evaluates internal compliance issues/concerns to ensure that issues/concerns are being appropriately evaluated, investigated and resolved.
    
8. Monitors and, as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
    
9. Identifies and oversees auditing and monitoring activities on potential areas of compliance vulnerability and risk; and develops/implements corrective action plans, in collaboration with department managers and the Compliance Committee, for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.
    
10. Provides reports on a regular basis, and as directed or requested, to keep the Compliance Committee and the Board of Trustees informed of the operation and progress of compliance efforts.
     
11. Oversees the reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
     
12. Establishes and provides direction and management of the Compliance Hotline and related reporting mechanisms.
     
13. Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline, (b) heightened awareness of Standard of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.
     
14. Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees, as well as ongoing general and specific, role-based training for all employees, volunteers, and Board members.
     
15. Monitors the performance of the Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.
     
16. Possesses knowledge of Continuous Quality Improvement principles and supports the hospital’s philosophy of performance improvement.  Participates on Quality Improvement teams as appropriate.