Oversee all aspects of the CGH Compliance Program.  Manage the day-to-day Compliance related activity for the organization, including staff training, complaint investigations, risk assessments, auditing and monitoring, and policy review and development.

ESSENTIAL FUNCTIONS

• Provide support to CGH staff for day-to-day compliance related questions and issues.

• Collaborate with other departments (e.g., Revenue Cycle, Risk Management, Health Information, Quality, IT, etc.) to identify compliance issues for investigation and resolution.

• Respond to alleged violations of rules, regulations, policies, procedures, and standards of conduct by initiating and completing investigations as necessary.

• Review OIG workplan on a regular basis.  Identify potential areas of compliance vulnerability and risk.  Complete Risk Assessments on potential problem areas and develop annual CGH Compliance Workplan.

• Respond to all government audits including, RACs, TPEs, Certs, CBRs, etc.  Identify other audit risk issues and perform internal reviews.  Maintain Audit Dashboard for record keeping and reference.  Continue to monitor any previous audit items as necessary for on-going compliance.

• Develop, maintain and revise policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.

• Responsibility for oversight and management of the Patient Rights chapter for Joint Commission.

• Serve as chairperson of the Audit Committee.  Prepare agendas and record minutes for Quarterly meetings.

• Serve as chairperson of the Compliance Committee.  Prepare agendas and record minutes for Quarterly meetings. 

• Maintain a record keeping system to document the ongoing operation of the compliance program.

• Monitor the performance of the CGH Compliance program on a continuing basis and take appropriate steps to improve its effectiveness.

• Provide reports on a regular basis to the CGH CEO and Board of Directors to keep senior management informed of the progress and effectiveness of the compliance program.

• Provides backup support for the Privacy Officer role, including assisting with privacy-related activities, investigations, regulatory requirements, and monitoring functions as needed to ensure continuity of operations.