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PURPOSE:
The Corporate Compliance department supports the agency in maintaining compliance in all areas of operations. The department focuses on promoting a culture of compliance, preventing, and detecting fraud, waste and abuse, confidentiality, and educating staff on their rights to report suspected non-compliance. The Corporate Compliance function ensures agency adherence to applicable laws, policies and procedures, regulations, standards and the Code of Conduct.
OVERVIEW:
The Chief Compliance Office/Privacy Officer is responsible for monitoring JB programs in order to assure that Jewish Board achieves consistently high levels of compliance with all applicable laws and regulations, policies and procedures and the agency code of conduct.
RESPONSIBILITIES include but not limited to:
- Develop, enhance, maintain and implement the corporate compliance plan and standards for the agency consistent with applicable laws and regulations.
- Strategically lead compliance major workstreams: Incident Management, Audits (external & internal), Regulatory Change Control, CARF accreditation, Grievances, Record Request, Risk Management, Privacy
- Identify, assess & mitigate systems issues to reduce compliance risk across the agency. Develop and implement an annual collaborative work plan to monitor specific areas of compliance risk.
- As Privacy Officer, oversee the development, implementation, maintenance of, and adherence to privacy policies and procedures regarding the safe use and handling of protected health information (PHI) in compliance with federal and state HIPAA regulation.
- Staff the Board of Trustees Corporate Compliance Committee and participate in the agency Risk Management committee.
- Report on general agency compliance to the Board of Trustees Corporate Compliance Committee, the Senior Staff team, the agency Risk Management committee, as required. Make recommendations for changes or improvements in the agency's compliance plan and implement such changes and determine efficacy.
- Review all new agency policies/procedures and general practices ensuring that they meet legal, ethical and compliance standards. Make recommendation for changes in any existing policy to ensure that they meet all regulatory standards.
- Review and update the Jewish Board’s Code of Conduct to set forth and communicate the standards of the agency and disseminate to all employees. Review and update Code of Conduct periodically to ensure its continuing relevance with the agency's mission and responsibilities. Conduct and/or oversee investigations of alleged fraud and other violations of the code of conduct.
- Respond to alleged violations of rules, regulations, and policies, et. al. by evaluating complaints and/or recommending the initiation of any inquiry. Apprise incumbent's supervisor(s) of any need to commence investigation of the status thereof. Such supervisor(s) will advise the Senior Staff and Executive Team accordingly. Whenever feasible, the appropriate department will conduct appropriate inquiries.
- Develop the internal program audit process, including annual schedules, training of audit team members. Create and maintain a hub of program audits including report findings and performance improvement plans.
- In collaboration with the Internal Audit Department, act as an independent auditor by reviewing compliance of all departmental procedures, policies and practices to ensure compliance with regulatory and agency requirements. Identify areas of potential compliance vulnerability and risk. Assist in the development of corrective action plans for the resolution of any risk issue, and ensure implementation. Provide guidance to the agency on how to avoid similar situations in the future.
- Develop internal mechanisms to communicate compliance requirements or changes in such requirements to all staff. Such mechanisms to include in-house and other notification venues.
- Conduct or oversee implementation of specialized risk related training on Assessment, Diagnosis and Treatment Planning, Client Abuse, Case Documentation.
- Manage and maintain a Compliance Hotline, to provide all staff with the ability to report any compliance breach without fear of retaliation.
- Develop in-house programs to train staff in compliance needs, regulations and issues. Part of this training will consist of one session to be held at the agency's employee orientation program.
- Coordinate accreditation activities across the agency.
- Act as an independent reviewer and evaluation body in investigations to ensure that all compliance matters have been appropriately addressed
- After completion of an investigation concerning a compliance breach, ensure proper reporting of violations occur to all necessary parties.
- Lead and manage the Compliance team. Create and sustain an environment that fosters team member engagement. Establish clear measurable objectives tied to department and/or organizational strategic goals. Coach, counsel and evaluate performance of direct reports.
- Formulate and monitor the agency medical records process, indexing and maintenance.
- Participate in monthly senior leadership meetings to support the overall agency development and guidance of the organization
ADDITIONAL FUNCTIONS MAY INCLUDE:
- Special projects as assigned by agency leadership.
CORE COMPETENCIES for the position include:
- Excellent leadership skills to guide employees and other management staff through processes that promote compliance
- Excellent engagement, facilitation & project management skills
- Systems thinker and process improvement skills
- Ability to evaluate complex compliance issues and make appropriate recommendations
- Strong verbal and written communication skills; as it relates to policy and procedures within the corporate compliance arena
- Demonstrated attention to detail, ability to compile & analyze regulatory information and make recommendations for process improvement
- Ability to work autonomously and collaborative with both internal and external teams.
- Experience with CARF accreditation, incident management, grievances & risk management
EDUCATIONAL / TRAINING / CERTIFICATION REQUIRED:
- BA/BS required. MS/MA/MBA/MPA/LCSW/LMSW preferred.
- OMH and OPWDD approved Incident Special Investigations Training for Justice Center reportable incidents (preferred but not required)
- Nationally recognized certification in compliance
EXPERIENCE REQUIRED / LANGUAGE PREFERENCE:
- Minimum of 5 years’ experience in issues of Corporate Compliance or Program Management.
- Minimum of 5 years of related experience, such as quality assurance and/or auditing.
- Knowledge of federal and state confidentiality laws/rules.
- Knowledge of human service agencies preferred.
- Prior experience in investigative techniques, procedures and/or program auditing preferred.
- Prior experience in interpretation of regulation and/or policy development and implementation preferred.
- Excellent organizational, time management, written and verbal communication skills.
- Knowledge of OPWDD/OMH/OCFS/ACS/OCFS regulations.
- Must demonstrate the ability to work independently and on teams in a fast-paced work environment
- Proven analytical and problem-solving skills.
- Ability to attend agency meetings, held during business hours & be onsite as needed.
- Must be able to be flexible for investigations and able to travel to sites as needed.
COMMUNICATION SKILLS:
- Ability to articulate the agency’s philosophy, mission and goals to a varied audience.
- Ability to interview a variety of managers, employees, consumers and their families.
- Ability to write reports, business correspondence and procedures for a wide audience.
- Ability to lead ad-hoc task forces and meetings, which may include all levels of management and employees.
- Ability to respond to inquiries or complaints, including those of a sensitive and confidential nature, from any of the following, if applicable, under a variety of circumstances, including adversarial situations: consumers, managers, employees, regulatory agencies, arbitrators, union representatives, vendors, or applicants.
- Ability to effectively present information to consumers, top management and staff in verbal and written formats.
- Ability to recognize the need for confidentiality of information and to maintain such confidences.
COMPUTER SKILLS REQUIRED:
- Knowledge of personal computers, standard software and database management.
- Proficient in Microsoft Office Suite.
- Ability to quickly adapt to agency computer applications.
WORK ENVIRONMENT / PHYSICAL EFFORT:
Noise level and hazards present are consistent with levels usually present in an office, education, rehabilitation, industrial, workshop or health related environment.
We are an equal opportunity employer that does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, marital status, veteran status, or any other status protected by applicable federal, state, or local law.
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