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 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