PUBLIC NOTICE

PUBLIC NOTICE

TITLE: Compliance, Risk, Survey Readiness Coordinator JOB CODE:

REPORTS TO: CEO DEPARTMENT: Administration

FLSA: Non-Exempt

SUMMARY

The Compliance, Risk, Survey Readiness Coordinator is responsible for ensuring that a healthcare organization operates in compliance with all relevant laws, regulations, industry standards and internal policies. They develop and implement compliance programs, policies, and procedures to promote adherence to ethical and legal standards while minimizing risk. This role is also designated as the organizations Compliance Officer. The coordinator will work closely with various departments to promote a positive culture of compliance to mitigate risks and ensure preparedness across all areas of responsibility. Additionally, the coordinator is responsible to ensure survey readiness, in conjunction with other leaders, for the organization often in a lead role. They work closely with various departments and stakeholders to assess compliance with regulatory and accreditation standards, identify areas of improvement, and develop strategies to achieve survey readiness. This plays a critical role in maintaining the organization’s reputation and compliance with industry standards and best practices.

STANDARD EXPECTATIONS

• Promotes a Positive Working Environment

◦ Conducts oneself in line with organization’s mission, vision, values and standards of behavior.

◦ Consistently demonstrates organizational values and standards of behavior.

◦ Accepts new responsibilities and challenges with a positive attitude.

◦ Consistently adheres to organizational policy.

◦ Assists in improving inter-departmental processes.

• Communicates Effectively

◦ Builds relationships and works collaboratively with other staff.

◦ Provides timely operational Risk Updates.

◦ Responds to communications in a timely manner.

• Performs Duties Efficiently and Effectively

◦ Efficiently manages their departments operations.

◦ Responsible as the leader in described areas to fulfill organizational requirements and needs determined by the District.

◦ Assists in development of department procedures, competencies and training of staff.

◦ Assists in identifying department process improvements.

◦ Directly manages day to day needs as described in the position summary.

◦ Provides guidance to others in applicable positions.

AREA OF RESPONSIBILITY

DUTIES & RESPONSIBILITIES

Compliance/Risk

Survey Readiness

• Develop and implement a comprehensive compliance and Risk programs: Design and implement policies, procedures, and systems to ensure compliance with applicable laws, regulations, and industry standards.

• Conduct compliance audits and assessments: Perform regular reviews and audits of the organization’s operations, processes, and documentation to identify and address any compliance gaps or risks and to identify potential areas of non-compliance and develop strategies to mitigate risks.

• Investigate compliance violations: Respond to reports of non-compliance, conduct investigations, and collaborate with relevant stakeholders to resolve compliance issues and implement corrective actions.

• Provide compliance training and education: Develop and deliver training programs to ensure that employees understand their compliance obligations, including relevant laws, regulations, and organizational policies.

• Maintain knowledge of regulatory changes: Stay up to date with changes in healthcare laws, regulations, and industry standards, and communicate relevant updates to key stakeholders within the organization.

• Monitor and report on compliance activities: Develop and implement monitoring systems to track compliance efforts, prepare regular reports on compliance activities, and provide recommendations for improvement to senior management.

• Liaise with regulatory bodies and external stakeholders: Establish and maintain effective relationships with regulatory agencies, industry associations, and other external stakeholders to stay informed about compliance requirements and collaborate on compliance initiatives.

• Promote a culture of compliance: Foster a positive compliance culture within the organization by promoting awareness, accountability, and ethical behavior among employees

• Prepare and submit required reports and documentation to regulatory bodies as needed.

• Prepare and submit required reports and documentation to regulatory bodies as needed.

• Conduct regular assessments: Perform comprehensive assessments of the organization’s compliance with regulatory and accreditation standards, including but not limited to; Centers for Medicare and Medicaid Services, Washington State Department of Health, Joint Commission, DNV, CLIA and others.

• Develop survey readiness plans: Collaborate with department leaders and subject matter experts to develop and implement survey readiness plans that address identified gaps and ensure compliance with standards.

• Conduct mock surveys: Organize and facilitate mock surveys to simulate the experience of an external survey or audit. Evaluate the organization’s performance, identify areas of improvement, and provide feedback to relevant departments.

• Provide education and training: Develop and deliver educational programs and training sessions to raise awareness of regulatory and accreditation standards. Train staff on survey processes, documentation requirements, and best practices to ensure ongoing compliance.

• Monitor regulatory changes: Stay up to date with the latest regulatory and accreditation standards, guidelines, and requirements. Assess the impact of new regulations on the organization and make recommendations for compliance adjustments as necessary.

• Collaborate with cross-functional teams: Work closely with various departments, including quality management, Infection Prevention, nursing, medical staff, Safety Emergency Management, Facilities and administration to ensure a coordinated approach to survey readiness and compliance.

• Document and report findings: Maintain comprehensive records of assessments, mock surveys, and compliance-related activities. Prepare reports summarizing findings, recommendations, and progress towards achieving survey readiness goals.

• Facilitate continuous improvement: Identify trends, patterns, and recurring issues based on survey findings and performance data. Collaborate with relevant stakeholders to develop and implement corrective action plans to address deficiencies and drive continuous improvement

• Actively participate in regulatory surveys and responsible for submitting reports, plan of corrections and other documentation as needed to ensure regulatory agency “good standing”.

QUALIFICATIONS

Required

• Understanding of compliance & risk program development and implementation.

• Ability to conduct audits, investigations, and risk assessments.

• Strong analytical and problem-solving skills.

• Excellent written and verbal communication skills.

• Ability to build effective relationships and collaborate with stakeholders at all levels.

• Attention to detail and ability to work independently.

• Understanding of Regulatory agency surveys in Healthcare and methods of readiness as well as compliance.

Preferred

• Bachelor’s degree in healthcare administration, business, law, or a related field.

• Strong knowledge of healthcare laws, regulations, and industry standards (e.g., HIPAA, Stark Law, Anti-Kickback Statute).

• Experience working in a compliance role within the healthcare industry.

• Professional certifications in healthcare compliance and risk (e.g., Certified in Healthcare Compliance (CHC), Certified Compliance and Ethics Professional, Risk Management (CPHRM) or similar).

• Experience working with State Department of Health, CMS, Joint Commission, DNV and others.

WORK LOCATION & SCHEDULE

Work location is in-person on District Premises. The typical schedule is Monday-Friday from 8:00AM to 4:30PM, but shall remain flexible to meet the needs of the District. This may include irregular working hours including nights, weekends and holidays. Travel to off-site locations for meetings, education and training may also be required.

WORK ENVIRONMENT AND PHYSICAL DEMANDS

This position is works in a clinical and Non-clinical environment. The position will frequently require walking, lifting, reaching carrying, kneeling, bending, stooping, pushing and pulling of objects weighing up to 20lbs. The position will occasionally require the ability to lift, and carry, up to 50 pounds and push or pull over 50 pounds, as well as require bending, twisting, squatting, reaching, reaching overhead, sitting and standing frequently. Occasionally the position requires climbing, kneeling and crawling. The position requires continuous finger dexterity and fine manipulation. All basic life functions such as hearing, seeing, speaking, standing and walking are required. The employee must demonstrate the ability to perform the essential functions of the position, with or without reasonable accommodation.

ACKNOWLEDGMENT

This position description describes the essential functions and qualifications for the position. This document does not exclude an opportunity for modifications consistent with providing reasonable accommodation. This position description is not a contract. Your signature indicates that you have read this position description and understand the essential functions and qualifications of the position and can perform the aforementioned with or without accommodation.

Compliance, Risk, Survey Readiness Coordinator- $22.10-$30.59

Applicants are also welcome to apply to http://www.earh.org

Published June 26 and July 3, 2024