Hospital Compliance Officer

Position Description Application materials will be reviewed in an ongoing basis until position is filled. Please allow up to (2) two weeks for processing of application materials. (Postmarks and faxes not accepted.) The eligible list established by this recruitment may be used to fill current and future position as they arise. Exam# 24/14M44/11SS Position Description Natividad is accepting applications for a full-time, permanent Hospital Compliance Officer to plan, organize, and coordinate various functions, operations, and activities pertaining to compliance at Natividad. This incumbent will develop, coordinate, and administer systematic hospital compliance programs; develop and administer goals, objectives, policies, and procedures, participate in hospital-wide strategic development and planning processes. The County of Monterey is committed to honoring the service and sacrifice of veterans and eligible military spouses and awards veterans’ preference points for this recruitment. To learn more about the eligibility requirements and the process, be sure to read the Hiring Preference for Veterans and Eligible Military Spouses section located towards the end of this job flier. Examples of Duties The Significant Duties Of The Position Are As Follows Plans, organizes, directs, and coordinates departmental compliance program activities to help ensure that hospital practices, policies, and procedures comply with County, State and Federal law as well as hospital standards and ethics Identifies and establishes Natividad’ s departmental standards to which employees will be held and the types of conduct which the compliance program is designed to eliminate; develops systems and methods for program implementation and evaluation; develops, implements, and audits program processes Develops, initiates, maintains, and revises policies and procedures for the general operation of the hospital compliance program and its related activities to prevent illegal, unethical or improper conduct; manages the day-to-day operations of the program; identifies the necessary participants in the compliance plan development and administration process; estimates resources necessary to accomplish the implementation of the program Monitors the legal compliance of hospital policies and procedures and recommends corrective actions as appropriate; investigates and resolves compliance violations and complaints; identifies policy and compliance issues and proposes solutions Coordinates the communications of compliance standards to all hospital employees; works with hospital 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 Directs the preparation of special and recurring departmental reports and analytical studies on complex compliance-related issues; monitors and conducts periodic audits and activities at greatest risk to ensure proper compliance Provides ongoing support, coaching and advice to hospital executive and management staff regarding compliance matters; works collaboratively with hospital management and staff to design systems and processes to assist them in addressing and preventing potential compliance issue Develops and maintains an organization Code of Conduct Manages channels for reporting problems and concerns without fear of retaliation Ensures appropriate screening is conducted to ensure that Natividad does not hire or conduct business with individuals or entities that have been debarred from participation in federal programs Acts as an independent reviewer to ensure that departmental compliance issues/concerns within the hospital are being appropriately evaluated, investigated, and resolved; develops/implements corrective action plans for resolution of problematic issues Stays abreast of legislation, trends, and issues pertaining to assigned areas; reviews court decisions, proposed legislation, and new program/policy; confers with legal Counsel regarding impacts of legislation and court decisions; recommends and implements hospital strategies Ensures that all assigned functions comply with The Joint Commission standards as well as the requirements of other regulatory agencies Responds to concerns and/or complaints from patients, the public, medical staff, and/or other hospital managers pertaining to assigned areas in order to maintain positive customer relations; researches and investigates issues; prepares written or oral responses as needed Participates in organizational strategic planning activities; serves on committees and task forces to address specific issues and/or represent the department as assigned; attends meetings and conferences as assigned; participates on task forces and committees as assigned Prepares and administers assigned budgets; monitors, evaluates, and approves operational expenditures within limits of authority; performs cost/benefit analyses as appropriate; plans and estimates future costs including capital expenditures as appropriate; justifies requests for new equipment and/or personnel Conducts meetings and gives presentations Conducts special studies and projects as assigned; researches and analyzes information; prepares statistical and narrative reports and documents as needed Performs other duties as needed Examples Of Experience/Education/Training MINIMUM QUALIFICATIONS Thorough Knowledge Of Local, State and Federal laws, rules, regulations, and ordinances pertaining to acute care hospital operations The Joint Commission requirements and standards for acute care hospitals Principles, practices, and techniques of compliance management, including program planning, fiscal/financial analysis, basic accounting, program implementation, administration and evaluation Effective research techniques utilized in the analysis of organizational compliance Best practices in developing and administering compliance programs Principles, practices, and techniques of policy development Report writing and basic statistics Principles and practices of business administration, including planning and organizing work, fiscal management, administrative problem solving, strategic planning and goal setting, and the implementation of effective solutions Working knowledge of: The organization and functions of County government Principles and practices of project management, including planning, organizing, coordinating, scheduling, and oversight of project progress Computer-based business applications, including those commonly used for word processing, database management, spreadsheets, e-mail communication, and Internet access Some knowledge of: Typical acute care hospital practices and routines Medical terminology Skill and Ability to: Plan, organize, direct, and coordinate compliance activities within an acute care hospital Read, understand, and apply relevant County, State and Federal statutes, rules, ordinances, codes, regulations, administrative orders, and other governing regulations Plan, develop and implement effective compliance policies and procedures in accordance with hospital goals and objectives Evaluate the quality and effectiveness of the compliance programs and activities and make necessary improvements Collect, interpret, and evaluate narrative and statistical data pertaining to administrative functions; prepare complex reports, memoranda, and other written materials Establish and control an operating budget Utilize standard business equipment Analyze and resolve problems and complaints Assess and prioritize multiple tasks, projects, and demands Assess and investigate sensitive and complex administrative and operational issues, evaluate alternatives and make logical recommendations based on findings Communicate clearly and concisely, both orally and in writing; effectively present information to groups and individuals Establish and maintain cooperative working relationships with others including physicians, nurses, administrators, attorneys, managers, and insurance carriers Maintain excellent public relations and provide courteous customer service Examples Of Experience/Education/Training The knowledge, skills and abilities listed above may be acquired through various types of experience, education or training, typically: Experience Five (5) years of increasingly responsible professional or analytical experience in a health care institution that included responsibility for administering and monitoring compliance activities, including at least one year in an acute care hospital setting. Experience should clearly demonstrate skill in administering healthcare compliance program functions and activities. Education/Training Completion of course work from an accredited college or university leading to a bachelor’s degree in health care administration, business administration, public administration, finance, health science, or a closely related field. Certification Professional certification as a Certified Healthcare Compliance Professional (CHCP) from the American Institute of Healthcare Management is highly desirable. Additional Information CONDITIONS OF EMPLOYMENT Natividad requires that all incumbents pass a pre-employment physical/medical assessment. Natividad will conduct a thorough background and reference check process which includes a Department of Justice fingerprint check. Employees who drive on County business to carry out job related duties must possess a valid Driver License for the class vehicle driven or have the ability to provide suitable transportation that is approved by the appointing authority. Employees must have and show their original Social Security Card and a valid Driver License or State ID prior to the first day of work (Social Security Card is required for payroll purposes only). Incumbents may be required to work all shifts, including irregular hours, nights, weekends and holidays. Incumbents may be required to work with potentially hazardous and infectious substances. REQUIRED APPLICATION MATERIALS AND SCREENING PROCESS** APPLICATION SUBMISSION: A completed Monterey County Application may be obtained from and submitted to the Natividad Human Resources Office, 1441 Constitution Blvd., Bldg. 300, Salinas, CA. 93906, or On-line applications may be submitted at www.natividad.com ; resume and license and/or certifications (if applicable) may be attached to your online application or emailed separately to: Scherersd@natividad.com . Resumes will be accepted in addition to, but not in lieu of the required application materials. For more information or to obtain regular paper application materials please contact the Natividad HR, 1441 Constitution Blvd.,(831) 783-2700, M - F, 7:30 a.m.- 5:00p.m. QUALIFICATIONS APPRAISAL: All licenses/certificates will be verified via primary source. Completed application materials will be competitively evaluated. Please note: The initial screening for this position uses ONLY the applicant's answers to the Supplemental Questions. Screeners (who are Subject Matter Experts) are not given the application and/or resumes at this point in the process. Therefore, your answers to the Supplemental Questions are critical. The best-qualified applicants will be invited to participate further in the process. QUALIFICATIONS ASSESSMENT: To further assess applicants' possession of required qualifications, this process may include an oral examination, pre-exam exercise, performance exam, or physical ability exam. ELIGIBLE LIST: Applicants successful in the Qualifications Assessment process will be placed on an eligible list for possible final selection interview. This eligible list will be used to fill current and future vacancies HIRING PREFERENCE FOR VETERANS AND ELIGIBLE MILITARY SPOUSES The County of Monterey is committed to honoring the service and sacrifice of veterans and eligible military spouses (i.e., surviving spouses of veterans, spouses of totally disabled veterans, and spouses of active-duty service members) and awards veterans’ preference points for this recruitment. To obtain a Veterans and Eligible Military Spouse Preference Application, please visit the Human Resources website or click on the following link: Click Here to View the Veterans and Eligible Military Spouse Preference Application To apply for veterans’ preference points, veterans or eligible military spouses must complete and email a Veterans and Eligible Military Spouse Preference Application with supporting documentation of their eligibility by the final filing deadline to: VeteransPreferencePoints@countyofmonterey.gov SPECIAL NOTES If you believe you possess a disability that would require test accommodation, please contact the HR Analyst for Natividad at (831) 783-2713. Employment is contingent upon acceptable documentation verifying identity and authorization for employment in the United States. If you are hired into this classification in a temporary/per-diem position, you will not be eligible for the benefits.