Job Description

REPORTS TO:  Chief Executive Officer
WORK WEEK:   Expectation of at least 40 hours per week
WAGE CLASSIFICATION:  Exempt
OSHA RISK CLASSIFICATION: Low 

SUMMARY POSITION STATEMENT

The Compliance and Risk Management Officer has principal authority and responsibility for the establishment, performance, and maintenance of the PCHS Management System, the internal controls necessary for the management of risk and compliance with all pertinent laws and regulations.

Regulatory and Legal Compliance – Identification of all compliance requirements and development and operation of all internal controls necessary to ensure and assure compliance with all requirements.

Risk Management – Management of the system for assessing and mitigating all safety, security, and other risks associated with PCHS health center operation.

The Compliance and Risk Management Officer is responsible for supporting the PCHS healthcare providers and team in the provision of and assurance accessible healthcare services to our community. He or she works closely with all members of the PCHS staff to accomplish intended performance, objectives, and goals of the organization. He or she provides guidance, support, and educational assistance to all staff members, as it pertains to risk management, legal and regulatory compliance, and ensuring quality healthcare for our patients.

ESSENTIAL FUNCTIONS/ROLES & RESPONSIBILITIES OF THE POSITION

1. Authority. The Compliance and Risk Management Officer is authorized to exercise independence and authority over a variety of activities across the operation of the health center. He or she is empowered to intervene in important areas of performance, including the organization’s ethics and practices, interaction with third parties, operational and clinical activities driven by internal controls, strategic planning and performance assessment, enforcement of personnel and company policies, staff training and competency, internal documentation and record-keeping, assessments of compliance and performance, risk assessment and mitigation, and investigation of incidents and allegations of inappropriate behavior and activities. The Compliance and Risk Management Officer is integrated into the business fabric and must enjoy the attention and support of the senior leadership of the organization.

   2.  Reporting.  The Compliance and Risk Management Officer is a member of PCHS’ senior management and will report directly to the CEO, who will oversee the individual’s performance. The Compliance and Risk Management Officer shall be assigned goals and objectives, performance targets, and be responsible for exercising good business judgement and upholding the organization’s commitment to quality patient healthcare, minimizing risk, compliance with regulatory and legal compliance, and supporting achievement of PCHS’s strategic and performance objectives.

   3.  Duties. The Compliance and Risk Management Officer must be competent regarding and be able to satisfy the duties and responsibilities ordinarily assigned to Compliance Officers and Risk Managers. He or she must be and remain familiar with pertinent expectations for the role(s), industry tools and techniques, the clinical healthcare environment, and related matters and competencies.

   The Compliance and Risk Management Officer shall be responsible for all of the following activities at PCHS:

   Overseeing and monitoring the development, implementation, and maintenance of PCHS’ Compliance and Risk Management Programs (the PCHS Management System).

I mplementing means of assessing compliance and performance to ensure satisfaction of operational goals and objectives, organizational efficiency and effectiveness, the prevention of injuries or breaches of security, and reducing the organization’s vulnerability to breaches of compliance requirements. Assessment shall include:

• Internal Audits
• Responding to red flags or reports of concern

Identifying opportunities for, assessing potential return, and defining and facilitating continual improvement of the operational and clinical performance of the organization.

Establishing, maintaining, and routinely assessing the Risk Management Plan for the organization.  

Establishing and maintaining programs for training, competency development, and competency validation of PCHS staff, including the development of content, supporting the training program(s), and providing new hire and refresher training to PCHS staff. Responding to employee concerns and questions.
Receiving, investigating, and resolving complaints or other allegations of unethical or inappropriate behavior or activities. When necessary, undertaking corrective action to remedy compliance concerns, performing necessary reporting or disciplinary action, and undertaking preventive action to prevent any recurrence.

• Managing control of PCHS documentation and record-keeping, including:
  • Creation of new documents and records
  • Facilitation of document review and approval
  • Release and control of documents and records
  • Routine review and update
  • Change Control
  • Release announcements and training
  • Document obsolescence

• Monitoring compliance with and effectiveness of existing policies and procedures and implements corrective actions as needed.  Gives particular attention to implementing procedures designed to improve quality of performance, as needed.

• Reviewing legal documentation and providing advice to PCHS staff: Guardianships, Custody and Foster Care, Medical Powers of Attorney, Declarations of Incapacity, Advance Healthcare Directives, Abuse and Neglect Reporting, Authorizations for Release of Information, Subpoenas and other Court Orders, etc.

Compliance. All staff positions require compliance with PCHS established policies and procedures. The Compliance and Risk Management Officer holds ultimate responsibility for compliance program operation, performance, and effectiveness.

Failure to comply with PCHS policies and procedures, which may include the failure to report any conduct or event that potentially violates legal or compliance requirements, will result in disciplinary action, up to and including possible termination.

POSITION REQUIREMENTS

Education: Legal education / Law degree preferred. Minimally a Bachelor of Science degree in health sciences, quality assurance, and/or related field, or related experience.

License: No license required. 

Experience: Minimum 4 years of experience in healthcare compliance and 4 years of experience in risk management preferred. Must be familiar with HRSA, CARF, DHSS, US HHS, HIPAA, OSHA, FTCA, FCPA, professional licensing regulations, HCP ethical codes and requirements.

PCHS is an equal opportunity employer and ADA compliant agency. 

Benefits include medical & dental insurance, PTO, floating holiday, life, AD&D and long/short term disability, 403b. 

Job Tags

Full time, Temporary work,

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