Summary:
Responsible for overseeing the adherence to established legal and regulatory compliance and privacy statewide for the NorthStar Care Community (NSCC). Acts as a convener, facilitator, collaborator, and coach to develop and drive a culture that values legal and regulatory compliance in all aspects of the organization.
Essential Functions:
- Ensures effective organizational strategic results are achieved, working collaboratively with others.
- Continuously leads efforts and collaborates with direct reports, key stakeholders, all NSCC affiliates, and NSCC leadership to oversee and take action to prevent and respond to legal, regulatory, privacy, and medical record non-compliance. Ensures that the compliance program is implemented throughout the organization.
- Oversees and participates in the development, maintenance, and continuous improvement of systems for auditing, monitoring, and tracking compliance program initiatives and compliance issues, and distributes results to appropriate staff as needed.
- Identifies areas of compliance risk through audit and monitoring activities, hotline calls, and department reports. Assists with ensuring compliance with contractual requirements and federal and state government reporting and regulations.
- Monitors organization’s compliance hotline and follows up on related hotline calls.
- Acts as a liaison between internal leaders and surveyors in a consultative manner with onsite survey; participates in accreditation activities including creation and submission of corrective action plans.
- As directed by the Associate Vice President (AVP) of Quality and Compliance, serves as a liaison with external auditors and participates in medical record requests and audit activity.
- Collaborates with the AVP of Quality and Compliance in annual and ongoing risk analysis activities for potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information.
- Serves as organizational Privacy Officer and follows up on internal and external HIPAA compliant patient record requests.
- Works collaboratively with the Security Officer to provide leadership, direction, and response in ensuring compliance with HIPAA and related standards.
- As directed by the AVP of Quality and Compliance, oversees and participates in the development, maintenance and distribution of policies and procedures for the organization.
- Follows up on customer inquiries to ensure concerns are addressed in a timely manner.
- Proactively keeps abreast of hospice and palliative care trends, best practices, and any anticipated legal and regulatory changes. Takes appropriate action to ensure a culture of excellence is maintained.
- As directed by the AVP of Quality and Compliance, oversees licensure, including the 855A, certification, credentialing, and other regulatory applications and renewals, communicating and following up with regulatory authorities or health plans as required.
- Proactively assesses, leads, participates, and promotes a culture of excellence and innovation at the employee, departmental and organizational levels, aimed at continually improving employee performance and engagement.
- Maintains oversight for recruitment and retention efforts consistent with the organizations vision, mission and values which ensure the engagement and retention of staff, within the designated area of responsibility, in collaboration with Human Resources.
- Proactively applies an inclusive management style and collaborates, as appropriate, with leaders, directors, and staff to ensure system linkage and integration.
- Effectively establishes, leads, facilitates, and participates in meetings at the individual, group and organizational levels, both within and external to the organization, with ease and comfort to achieve desired outcomes.
- Maintains oversight of all allocated resources within a designated region including but not limited to time, expenses, supplies and labor and ensures pre-determined financial margins and/or outcomes are achieved.
- Maintains oversight of all employee compliance related performance outcomes within the State of Michigan and ensures that a culture of accountability and responsibility is fostered to achieve desired performance outcomes and staff competency.
- Proactively works to coach and/or mentor direct reports and subordinates to improve performance. Ensures that appropriate corrective action and performance improvement plans are administered per organizational guidelines, when appropriate, in collaboration with Human Resources.
- Ensures internal and external education, training and activities for self and staff to promote personal and professional growth and to ensure staff competency is maintained at all times.
- Promotes NorthStar Care Community in all professional external and internal contacts. Proactively promotes census growth within designated region(s) and seeks to offer care that meets the unmet diverse needs of the community.
- Models and promotes knowledge of palliative care and hospice philosophies and articulates and promotes the organization’s vision, mission, and values locally, statewide, and nationally, when appropriate.
- Proactively participates and collaborates externally, with various individuals and/or groups, to establish various benchmarks and standards as it pertains to hospice and palliative care, locally, statewide, and nationally, when appropriate.
- Upholds the organizational Code of Conduct, policies and procedures and all regulatory and legal requirements.
- Models the NorthStar standards to care for every person, every time, 100% of the time.
Supervision: Reports to the AVP of Quality and Compliance. Supervises Compliance Coordinators. Coaches and mentors all direct reports and is responsible for overall management of all staff within designated geographic regions(s) of responsibility.
Working Relationships:
Internal: Extensive contact with administrative, management and leadership staff across the organization both within the designated area of responsibility and with other individuals and departments within the organization. Works with the AVP of Quality and Compliance who then works directly with the President/CEO and Board of Trustees regarding internal matters of importance related to legal and regulatory compliance.
External: Contact with community physicians, agencies, facilities, and other programs as needed, to promote growth and understanding of hospice and palliative care and ensure that service excellence is attained within the community. Collaborates with federal, State, and regional agencies as necessary.
Qualifications:
- A minimum of a Bachelor’s degree in a clinical and/or administrative field required. Master’s degree preferred.
- Minimum of five (5) years of experience in quality service improvement and regulatory compliance required.
- Three (3) to five (5) years of previous management experience that entailed significant accountability for adherence to established legal and regulatory compliance requirements required.
- Graduate of an accredited school of nursing with a current license to practice in the State of Michigan as a Registered Nurse required. Certification in hospice nursing (CHPN) preferred.
- Healthcare compliance certification is required and should be in place upon hire or obtained within one (1) year of hire date.
- Operational experience in hospice/home care setting strongly preferred.
- Expertise in regulatory requirements and compliance as it pertains to hospice is required.
- Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources required.
- Must possess emotional intelligence and the ability to promote positive, constructive relationships with communication and collaboration at all levels.
- Excellent interpersonal skills with the ability to comfortably interact at all social levels and with colleagues from many different backgrounds, ethnic origins and skill levels required.
- Must possess sound judgment; effective organizational, prioritization and follow-through skills; attention to detail; accuracy; dependability; tact; and ability to maintain confidential information.
- Understands performance improvement and can communicate and operationalize performance improvement initiatives at the departmental and organizational level. Demonstrated ability to produce results while still being a team player required.
- Ability to communicate effectively and professionally in writing and verbally to perform management duties and to promote good working relationships.
- Ability to effectively use technology in support of management and clinical operations.
- Must be able to read, write and speak English fluently and be able to communicate orally and in writing in internal and external relationships for all essential job functions.
- Ability to prioritize multiple demands. Demonstrates integrity and flexibility and participates actively in change and quality improvement initiatives.
- The physical demands of the position include: vision, effective speech and hearing for extensive telephone contact; repetitive motion; traveling; driving or riding in motor vehicle; standing, sitting, walking, bending, reaching, and stretching; lifting up to twenty (25) pounds unassisted.
- Must have reliable transportation in order to be able to travel and maintain the rigors of a busy schedule. Frequently works variable hours/days; activities and workload may require extended days.
- Must be physically and mentally capable of performing all essential duties required of the position.
- Must be eligible to work in the United States.
