Compliance Officer - TMN/Critical Access Hospital

SUMMARY

The Compliance Officer Critical Access Hospital and Ambulatory Clinics: (1) implements, manages, and monitors an effective compliance program for TMC Health Critical Access Hospitals and Rural Health Clinics in Benson, AZ. and Wilcox, AZ, and TMCOne/Tucson Medical Network ambulatory physician clinics to prevent and detect illegal, unethical, or improper conduct; (2) serves as the HIPAA Privacy Officer and, as such, oversees implementation and monitoring of a privacy program designed to support adherence to policies, regulations, and laws relating to the HIPAA Privacy Rule; (3) manages operational activities of the Corporate Compliance Department; (4) serves as Chair of the Benson Hospital and Northern Cochise Community Hospital Compliance & Privacy Committee and the TMCOne Governance Council.  The Compliance Officer reports to the TMC Health Chief Compliance Officer.

ESSENTIAL FUNCTIONS:

·        Oversee a Compliance Program that addresses all program elements recommended by the Department of Health and Human Services Office of the Inspector General (OIG).

·         Manage an annual compliance work plan for each specific entity.

·         Maintain policies to address key compliance areas and privacy matters as described by the OIG and the HIPAA Privacy Rule and to support standards of expected conduct as outlined in the TMC HealthCare Code of Conduct.

·         Direct delivery of education regarding compliance expectations and appropriate management of compliance issues and risk areas.

·         Conduct annual compliance risk assessments and periodic program effectiveness assessments.

·     Oversee the operation of systems designed to detect illegal, unethical, or improper conduct, including privacy incidents, as well as those systems designed to receive and track internal and external compliance complaints, inquiries, and investigations.

·         Investigate and act on matters related to compliance.

·         Regularly report to the TMC Health Chief Compliance Officer on the status of the compliance program.

·         Manage the activities of the Corporate Compliance Department.

·       Oversee approval and distribution of TMC Health Compliance and HIPAA policies, including supervision and oversight of the policy retention site and maintenance of policies and processes for creating, reviewing, revising, and updating policies.

·      Chair the Benson Hospital and Northern Cochise Community Hospital Compliance & Privacy Committee and the TMCOne Governance Council and, in doing so, regularly report to operational leaders on the status of the compliance program.

·     Assist in establishing methods to improve efficiency and quality of compliance-related services and to reduce TMC Health’s vulnerability to fraud, waste, abuse, and other organizational compliance risks.

·         Adhere to TMC Health organizational and department-specific safety and confidentiality policies, standards, and values.

·         Adhere to, and support team members in exhibiting, the TMC Health values of integrity, community, compassion, and dedication. 

·         Perform duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor’s degree required, preferably in a related field, e.g. law, auditing, business, healthcare administration.

EXPERIENCE:  Six (6) years of experience in healthcare corporate compliance with a minimum of three (3) years’ experience in leadership.

LICENSURE OR CERTIFICATION: Certification from the Compliance Certification Board (CCB) or comparable certification or Juris Doctorate.

KNOWLEDGE, SKILLS AND ABILITIES:

·         Develop policies and procedures and oversee policy and procedure implementation.

·         Communicate effectively orally and in writing with all levels within and outside TMC.

·         Appropriately handle confidential and/or sensitive information.

·         Successfully keep administration informed of activities, needs, and problems.  

·         Perform critical thinking and analysis. 

·         Advise on compliance gaps in standards and objectives.

·         Collaborate with relevant personnel and departments on recommendations or action plans for compliance with policies, laws, and regulations. 

·         Effectively use computer software tools to assist in accomplishment of duties (e.g.  Excel, Word, Outlook, PowerPoint).

·         Investigate, analyze, and study activities affecting TMC operations. 

·         Digest and communicate regulatory, industry, and other business guidance.

·         Strong orientation to deadline and detail.

·         Decisiveness and demonstrated exercise of good judgment under pressure.

·         Manage a diverse and demanding workload.