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Position Description

PPRIORITY SCREENING DATE: Sunday, December 1, 2024 at 11:59 pm for a guaranteed review. All application materials received after this date 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.

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 CA Driver License for the class vehicle driven.
• Employees must have and show their original Social Security Card and a valid CA Driver License or CA State ID prior to the first day of work.
• Incumbents may be required to work all shifts, including weekends and holidays
• REQUIRED APPLICATION MATERIALS AND SCREENING PROCESS

SPECIAL NOTES