POSITION SUMMARY
The position is responsible for the working cohesively and under direct supervision of the Chief Compliance Officer (CCO) in implementation and monitoring of the TCRHCC Compliance Program to ensure compliance with Federal health care laws, Accreditation standards and reduction of liability for the Corporation. Incumbent will assist in monitoring, documenting and following up regarding issues related to Federal health care law that are identified by the CCO. Incumbent is responsible for the assisting in the oversight and follow up, documentation, and education of staff, of all risk management and issues for TCRHCC to include all external extensions of the hospital. The Corporate Compliance Technician will work in tandem and take direction from the CCO in assuring that the organization is in compliance with Risk Management and Corporate Compliance Plan as required for TCRHCC Organizational By Laws and Policy and Procedures in addition to other federal, state and tribal regulations.
ESSENTIAL FUNCTIONS
Works under the direction of the TCRHCC Chief Corporate Compliance Officer in coordination with the Corporate Compliance Plan and Program.
- Assists in maintaining and revising policies and procedures for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
- Develops succession plan for Corporate Compliance Program.
- Assists with the Corporate Compliance Committee in taking minutes and preparing agendas.
- May assist CCO for orientation and education of TCRHCC staff to address of corporate compliance management procedures, techniques, and regulations.
- Trains and assist staff with the occurrence reporting system, tracks issues, analyzes and refers them to the appropriate work center for resolution.
- Identifies tracks and documents with assistance from CCO all Potentially Compensable Events (PCE) in the facility.
- Maintains documentation and assures communication to and from all appropriate staff.
- May assist with scheduling meetings for the Patient Safety/PI designee in identifying Sentinel Events and assists as needed the Patient Safety/PI designee to coordinate Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA),
- Assists in coordinating, tracking, and maintaining tort claims in a secure manner under the supervision of the CCO.
- Notifies and works with providers named in a tort claim; duties with collaboration with the CCO
- Assists CCO in coordination of malpractice subpoenas received for TCRHCC; works with the US Assistant Attorney, Navajo Area Office, IHS Regional Counsel, TCRHCC general legal counsel and TCRHCC staff to assure strict adherence to the correct process.
- May coordinate depositions and interviews, including arrangements for room reservations, scheduling, document presentation and maintenance of records under supervision of the CCO.
- Under supervision of the CCO, assists in proactive responses to patients, their families, and employees following the investigation of potentially compensable events and asserted legal actions.
- Works with all hospital departments to ensure that adequate policies and internal systems and controls are in place to promote compliance in specific areas.
- Assists CCO in promoting detection and reporting of violations, including a system to solicit reports while ensuring anonymity and protection from retaliation.
- Assists in investigating and documenting issues that are determined to be compliance issues by the CCO or Chief Executive Officer (CEO).
- Maintains records of all investigations, including, but not limited to a description of the alleged violation, a description of the investigative process, according to the requirements of the Corporate Compliance Program.
- Assists in on-going education and training on compliance requirements under supervision of the CCO.
- Assists with regular reviews and audits, utilizing both internal and external auditors of system-wide operations to monitor compliance with Federal healthcare legal requirements.
- Maintains records of audits performed and submit audit reports to the CCO and CEO.
- Relays reports of potential compliance violations to the responsible management personnel with recommended or required action under supervision of the CCO
- May assist in monitoring Contracting Officer fully complies with the duty to attach appropriate business associate agreements to all business associates and business contract agreements;
- Assists CCO in drafting an annual work plan to govern compliance efforts during the subsequent year, with an emphasis on education and training opportunities, for approval by the Corporate Compliance Committee.
- Assists in documenting employee attendance at compliance and education sessions is mandatory and reports non-attendance to the manager and Human Resources.
- Assists in creating reports quarterly and annually with the CCO to the Board of Directors on the status of the Corporate Compliance and Risk Management Program and reports any corrective actions taken along with evidence of resolution.
- Assists in HIPAA Investigations and acts as a witness in interviews with the CCO.
- Responsible for electronic health records data entry pertinent to patient service role.
- Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer satisfaction.
- Other duties as assigned.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an individual to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical:
The Incumbent must have the ability to sit, walk, drive, crouch, twist, maintain balance and reach for prolonged periods meaning greater than ¾ workday. Must be able to frequently (1/2 workday) stand and occasionally (less than ¼ day workday) climb, kneel, and bend. Incumbent must be able to lift, push and pull up to 50 pounds. Must also have the ability for far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and, hearing overhead pages through a loudspeaker for prolonged periods of time (3/4 workday). Incumbent must have the hand manipulation ability with simple grasping, firm grasping, fine manipulation and use of keyboards. Employee may frequently be exposed to infectious diseases. The position is mostly sedentary, frequent standing, walking, and bending to make presentations and to perform functions of investigation; light to moderate reaching, lifting in the performance of normal office functions.
Mental:
Incumbent must have the mental and emotional ability for prolonged periods of time to: cope with high level of stress; make decisions under high pressure; concentrate; handle a high degree of flexibility; handle multiple priorities in stressful situation; work alone; demonstrate high degree of patience; and, work in areas that are close and crowded. Incumbent is expected to frequently cope with anger/fear/hostility of others in a calm way; and, adapt to shift work. Occasionally the incumbent may need to be able to manage altercations.
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NECESSARY QUALIFICATIONS
Education:
Associates Degree in General Studies or health care business related field
Experience:
- Two (2) years of experience in an acute health care setting, with a basic understanding of Patient Safety and Compliance regulations.
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Reliable and dependable; reports to work as scheduled without excessive absences.
- Excellent organizational skills, communication skills; and analytical skills
- Proven record of excellent customer service and teamwork
- Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
- Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
- Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC.
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