Registed Nurse/Compliance and Risk Management Officer
Responsible for the professional management of a comprehensive regulatory compliance and risk management program for the hospital, Veteran’s Home, and Spanish Peaks Family Clinic’s. Oversees the Compliance Program and provides leadership, direction, and accountability related to compliance matters within the organization. Implements measures to reduce risk and ensure the facility’s obligations under prevailing health and safety legislation and the applicable federal and state regulations. Promotes ethical behavior in the organization consistent with the Compliance Program’s Code of Conduct.
The incumbent performs complex program management and administrative duties and serves as a member of the hospital’s executive management team to ensure that assigned programs, functions, and operations conform to organizational goals and objects, as well as state and federal regulations. Develops, coordinates, and administers systematic hospital risk assessment and compliance program. Develops and administers goals, objectives, policies and procedures related to risk management and regulatory compliance. Collects and analyzes statistical data and reports to identify and determine compliance issues and areas of risk. Prepares reports to fulfill the requirements mandated by government rules and regulations. Advises leadership, directors, and managers on carrying out policies related to healthcare compliance in accordance with federal and state regulations. Develop, implement and monitor programs to reduce facility risk. Ensure high standard of quality care by putting forth measurable best practices and establishing benchmarks to monitor compliance.
ESSENTIAL FUNCTIONS INCLUDED BUT ARE NOT LIMITED TO:
A. Regulatory Compliance Functions:
· Implement and manage an effective regulatory compliance program.
· Develop, revise, oversee and enforce the facility’s compliance program.
· Develop, review and recommend risk-based changes to facility policies and procedures to ensure compliance with all applicable state and federal regulatory requirements, rules and laws.
· Conduct regular compliance audits and create and manage effective corrective action plans in response to audit discoveries and compliance violations; Acts as an independent reviewer to ensure that departmental compliance issues/concerns within the facility are being appropriately evaluated, investigated and resolved.
· Advise leadership, directors, and managers on the hospital’s compliance with laws and regulations through detailed reports. Provide quarterly status report to the Board of Directors on compliance progress and issues.
· Provides ongoing support, coaching, and advice to facility executive and management staff regarding compliance issues; works collaboratively with facility management and staff to design systems and processes to assist them in addressing and preventing potential compliance issues.
· Assess company operations to determine compliance risk and makes recommendations for changes to maintain compliance.
· Regularly audit company procedures, practices and policies to identify possible weakness or risk.
· Ensure all employees are educated on the latest regulations and accompanying policies and procedures. Coordinates the communication of compliance standards to all hospital employees; works with facility department managers as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees and ongoing training for all employees and managers.
· Creating, coordinating, and managing reporting channels for compliance issues
· Develop and maintain a library of compliance resources and disseminate relevant compliance resources to appropriate staff.
· Keep abreast of, monitor, and analyze regulatory trends and changes in regulations, rules, and laws. Determine which regulations the facility is subject to and advise management of the operational impact of such trends and changes.
· Maintains appropriate project management work plan documents and works on projects of a diverse scope.
· Represents the organization during regulatory surveys and on compliance issues with external parties (state, federal, and local government bodies).
· Directs the preparation of special and recurring departmental reports and analytical studies on complex compliance-related issues.
· Annually reviews the OIG work plan and other appropriate State, Federal and VA regulations as needed to assess the appropriate updates to the Compliance Code of Conduct for the next calendar year. Forwards updated/revised documents to the Board of Directors for approval, and once approved, distributes revised copy to all facility departments.
· Leads the development, implementation, and ongoing monitoring of all business associate agreements to ensure privacy requirements and organizational responsibilities are met.
· Works with the HIPAA privacy officer and facility HIPAA security officer to address complaints, breeches and other compliance issues as necessary.
· Oversees and participates in the process for receiving and investigating complaints for the Hospital, Veteran’s Home, and clinics; Documents, tracks and acts on these complaints.
· Managing the Policy and Procedure/Compliance software process.
B. Risk Management Functions:
· Plans, organizes, directs, and coordinates departmental risk assessment activities.
· Receives, reviews, and takes appropriate action on information regarding potential and actual risk events and accidents within specified time frame; records, collects, documents and maintains data.
· Maintains risks statistics in compliance with regulatory bodies, ensuring integrity and security of all parties; maintains accurate and current files on all medical-legal claims.
· Keep up to date with health and safety legislation and guidelines and advise facility management on legislation development which may affect Safety, Health and Welfare and Work.
· Be familiar with the National Standards for Safer Better Healthcare and participate in the self-assessment process.
· Establish appropriate structures and processes in relation to risk reporting, incident management and Health and Safety within the facility.
· Review the facility’s Safety Statement and related policies/procedures/guidelines, in consultation with relevant personnel and with due regard to prevailing legislation and make recommendations to the CEO as necessary.
· Coordinate the development and review of relevant/required risk and incident management policies, procedures and guidelines.
· In conjunction with appropriate staff, assist in identification of potential risk through risk assessment, analysis of accidents/incidents and near miss incidents, periodic safety inspections and or/audits. Make recommendations to reduce, prevent or eliminate risks identified.
· Maintain a risk audit database and liaise with department heads in relation to issues arising.
· Enter all accidents/incidents/near miss incidents onto the national Clinical Indemnity Scheme computer database and generate reports.
· Coordinate the claims management function.
· Provide quarterly and ad hoc reports to the CEO and the Board of Directors highlighting trends in relation to accidents/incidents.
· Develop, implement and lead health and safety training for new employees and existing employees.
· Maintain records of all health and safety training.
· Participate on the Hospitals Health, Safety and Security Committee and Major Emergency Planning Committee.
· Be familiar with all aspects of implementation of the facility Risk Management Strategy, Fire Plan, and Major Emergency Plan.
· Promote an awareness of Health and Safety in the workplace.
· Promote and maintain a safe working environment for all staff
KNOWLEDGE, SKILLS, ABILITIES
· Stays abreast of legislation, trends, and issues pertaining to risk management and regulatory compliance as it pertains to healthcare.
· Ability to read, understand, interpret, and apply State and Federal regulations, rules and laws.
· Knowledge of risk management tools and programs and ability to identify, assess and remediate potential and actual risks to patients, staff, and the facility.
· Knowledge of statistical methodologies and ability to collect, interpret, analyze and evaluate statistical data pertaining to regulatory compliance and risk management issues; Prepare complex reports, memoranda, and other written materials to communicate findings.
· Ability to communicate statistical data in simple language in order to drive process improvements and ensure regulatory compliance.
· Communicate clearly and concisely, both orally and in writing; effectively present information to groups and individuals.
· Establish and maintain cooperative working relationships with other including physicians, nurses, administrators, managers, and employees.
· Ability to stand by difficult decisions and be more influenced by right versus wrong than by relationships. Willing to take the lead in setting the tone for corporate integrity.
· Take a proactive approach and be vigilant to potential risks and compliance issues and be able to enforce a mandatory reporting policy in order to seek out any compliance breeches.
· Be ethical and principled.
· Knowledge of and ability to apply project management principles.
· Knowledge of quality improvement methodologies and tools.
· Education: A Bachelor’s degree in Nursing (Master’s degree preferred).
· At least three years working in a heavily regulated environment, interpreting and applying regulations, and conducting compliance audits (healthcare experience preferred).
· Two years working in risk management or employee safety.
· Must possess a nationally recognized certification in a healthcare compliance (healthcare compliance; healthcare research compliance; healthcare privacy compliance) at hire or within one year of hire.
· Risk Management certification preferred.