The Compliance Officer is responsible for assisting in the oversight of all compliance and improvement aspects for the facility. The Compliance Officer will analyze facility operations and needs to determine potential enhancements or improvements to clinical procedures and operational activities and will develop and/or recommend supporting policies and procedures. The Compliance Officer will collaborate and coordinate in implementing plans and programs particularly in the areas of performance improvement for process and outcomes.
Essential Duties and Responsibilities
Serves as in-house expert on Joint Commission Standards requiring in-depth knowledge of policies and procedures within the Facility in order to ensure compliance.
Proactively audits and monitors practices within the Facility to ensure that appropriate standards are in place and are being implemented effectively.
Works with leadership team to address and resolve operational issues as they arise.
Develops and oversees action plan to prepare for periodic surveys.
Conducts training and education related to Joint Commission standards.
Drafts policies as needed for compliance with standards within Facility.
Manages the Facilities compliance program to include privacy, security, safety/risk management, fraud and abuse monitoring, tracking, trending and reporting.
Responds effectively to potential violations of applicable standards and develops and oversees a corrective action plan for resolving them.
Oversees Quality processes of the facility to include the following:
Reviews data to identify trends regarding accidents and/or occurrences and recommends corrective action plans to management.
Directly refers all incidents with claims involving actual or potential injury to patients, visitors and staff to higher authority.
Responsible for conducting Root Cause analysis investigations and prepares summary reports to include recommendations based upon the learnings obtained from the investigation.
Prepares monthly reports for Quality Council meeting and the Patient Safety Council meetings.
Participates in FLASH treatment team meetings.
Responsible for the technical writing and preparation of board reports, state and federal reports for facility license.
Provides support to Facility CEO as needed.
Prepares agendas, notices and minutes for compliance meetings and monitors action plans to accomplish meeting goals.