Compliance Officer

PositionSummary:

TheComplianceOfficerpromotestheTohonoO'odhamNationHealthCare's culture thatencouragesethicalconductandcommitmentto complianceandensures duediligencetopreventanddetectillegalconduct.Theworkinvolvesinvestigationandanalysisofa varietyofcompliance issues throughouttheNation'shospitalandclinics.

Scopeof Work:

InvestigationandanalysisprojectedforproposedandexistingTONHCprogramsforefficiency,effectiveness,andcompliancewithregulatoryandlegalrequirements.Developsinternalcontrolsthatadequatelymeasuresandmanagesrisksandincludesstandards,procedures,capableofreducingtheprospectofcriminalconduct.Theincumbentis undertheQualityManagementDivisionreportingtotheQualityAssurance Officer.

EssentialDutiesandResponsibilities:

Organization - 50%

• ExercisesoversightresponsibilityfortheTONHCcomplianceandintegrityUsestheTONHCCompliancePlan,Federal SentencingGuidelines,andtheOfficeofInspector General (OIG)Programguidestoimplementoversightfunctions.
• RecommendsComplianceProgramrevisionsto meetchangesinthe organization'sneeds,business,and regulatory environment,to improveitseffectiveness.
• Providescomplianceinformationto helpTONHCmanagementfindnewwaysto improve decisionmaking,quality,andreduce itsvulnerabilitytofraud,waste,and abuse.
• Ensures thatindependentcontractorsandagentswhoprovidemedicalservicesareeducatedandawareof theTONHCCompliancePlan.
• Researches and assists inapplyingregulatorycompliance requirements.
• WorkscloselywithChiefLegal Officer (CLO), whenappropriatetoreviewinvestigationsthatresultinviolationsoflawthatmayrequirereportingtotheOfficeoftheInspectorGeneral (OIG),appropriateagenciesorfiscal intermediary.
• Conductsinvestigationsofallegedviolationsoflaw,standardsofconduct,oranyothersystempoliciesand procedures withinTONHC.
• Responds toemployeesbyensuringthatreports(phone calls, emails,andinterofficemail)are appropriatelyinvestigatedand resolved. TheComplianceOfficerwillensurereportsremainanonymousorconfidentialto the extentpossible.
• Implements,documentsandmaintainsa coordinatedlegislativeandregulatorycompliance programthatmeetsthe expectationsofTribal,Stateand Federal regulatorsandGovernment programs.
• Staysabreastofchanges toandclarificationsof Federal Guidelinesregardingmeaningful use andEHR certification criteria.I n referencetocompliance,willberesponsiblefordevelopingtoolstomonitoranddevisereportingmechanismsforhigh-riskareasidentifiedinauditsforTONHC.
• Serves as thechairpersonofthecomplianceDevelopsagendas,reports,andinformationas requestedbythecommittee,CEOandGoverningBody.
• Managesthe compliance department'sadministrativeThisincludesorganizingandmaintainingrelevantfiles,preparingnecessary reportsonactivitiesandreportingtovariousTONHCcommittees.
• Effectivelyincorporatesthecompliance programorganizational committeereporting structure.This requirement willalso consistofappropriate informationandreportingsystemsothattheCEO andGoverningBody mayexercisetimelyandinformedjudgmentsconcerningthe healthcare'scompliancewithapplicablelaw.
• Coordinatesresourcestoensure ongoingeffectivenessofthe compliance program.
• Ensures coordination withotherdepartmentsincludingtheRevenueEnhancementBranch,HumanResources, Information TechnologyandClinical Services toensureeffectiveimplementationofTONHC'scommitmenttocomplianceandintegrity.
• Reportsdirectlytothe TONHC Quality Assurance OfficerwhowillensurethattheCEO andtheGoverning Body arekeptapprisedregardingcompliancematters.
• Stopssubmissionofdata thathe/she believescontainsmaterial errors.

CommunicationandTraining20%

• Communicatestheimportanceofcomplianceto seniormanagement,andtheTONHCstaff,including promoting 1)use ofthecompliance hotline,2)increasesawarenessofprinciples ofintegrityandcompliance,and3)understandingofnewandexistingcomplianceissues andrelatedpoliciesandproceduresusingtheTONHCcomplianceplan toeducatestaff.
• ConductstrainingtonewandexistingemployeesoncomplianceWillberequiredtopresent compliance educationtonewstaffat themandatorynewstafforientation.Complianceeducationwillbepresentedtostaffat generalstaffmeetingsanddepartmentalmeetings,andanyotherforums as requested.Keeps documentationofnewstaffattendance at educationsessions.
• Developsandmaintainsproductive relationshipwith supervisorsandmanagementstaffincludingthe regulators, andotherrelevantexternalparties.
• WorkswithTONHCleadershiptoprovide adequate informationtoensure thattheyandtheiremployeeshavetherequiredinformationandknowledgeofregulatoryissues andrequirementstocarryouttheir responsibilities ina lawfulandethicalmanner.
• Developsopenlinesofcommunicationincludingnon-retaliation.
• Developsandpresentsquarterlycompliance reportstoSenior Management.

Monitoring,AuditingandEnforcement- 20%

• Conductsperiodicreviewstoassessadherenceto TONHCcomplianceplanReviewsshallincludeconfirmationthatappropriaterecordshavebeencreatedandmaintained.
• Takesappropriate actiontoaddress issues/problemsuncoveredinan auditSuchactionshall include training,CompliancePlanrevisions,andComplianceProgramrevisions.Follow upmonitoringwillbeconducted toensurecorrective actioneffectiveness.
• WorkswithThirdPartyBilling,Finance, HealthInformationManagement(HIM),andHealthCareProvidersto ensure auditsarecompleted.Auditswillfocusonthebillingprocess as identifiedwithintheorganizationspoliciesandprocedures.
• Conductsreviewsfocusedoncompliancewithspecific rulesandpoliciesidentifiedinauditsbytheOfficeof Inspector General (OIG) as beingproblematic andapplicabletoTONHC.
• Examinesandreviewsresultsofauditswiththe Senior Management. TheComplianceOfficerisresponsibletotake promptactiontocorrectproblemsofanydeviation caused byimproperprocedures,misunderstandingofrules,includingfraudandsystemproblems.
• Ensures thatTONHCstaffimplementCorrectiveActionPlans as a resultof an outsidesurveyand/or audit.
• Coordinatesauditsinotherareassuch as claimsdenial,breachesofprivacy,licensures,referralpracticesandstandardsof care.
• CoordinatesinvestigationswithCLOformajorviolationsoflaworconductsoroverseesinvestigations, as appropriate.
• Independentlymanagesandresolvesunanticipatedissues as theyTheCEO setsoverallTONHCgoals,andtheincumbentisexpectedtoachieveallgoalsbydeterminingindependentstrategies,plansand priorities.
• Worksindependentlyandis expectedtomake immediatedecisionsonbehalfoforganizationinregardtosuspectedfraud,wasteandConflictofinterestshallbeavoidedtoallowindependentandobjectivereviewsfororganization.
• Keeps Quality Assurance Officerabreastofdecisionsandimmediatelyassuringinitiationofcorrective action based onobjective andsubstantiatednon-complianceinformation.

Policies, ProceduresandStandards- 10%

• IdentifiesandassessareasofcomplianceriskforTONHCanddevelopsandupdatesannuallytheRiskMatrixandAssessmenttoolthatidentifiesriskareaswith an assessment,actionplanandresponsiblestaff member.
• TheComplianceOfficerisresponsibleforcoordinatingall auditsandmonitoringhigh-riskEducationand training inriskareasaredocumentedinreportstosupervisor.Workswithmanagementtoensuretrainingisconductedforemployeeswhowork intheseareasincludingthose whotransferorarenewtothedepartment.
• WorkscollaborativelywiththeRevenueEnhancementDirectortoenforcecompliancetotheIHS Internal Controls Policyensuringnofraudulentclaimsaresubmittedtothirdpartypayers.Ensuresresponsibleparties are cognizantanduse accurate documentation,billing,andcoding.
• CoordinatesmonitoringandauditingwithotherstafftoensurecompliancewithHIPAAand Privacy Act Law.
• DevelopstrackingtoolusingtheRPMS systemtomonitorelectronicprotectedhealthinformation as the useoftheelectronic healthrecordbecomesstandardoperatingprocedureto conducthealth care.

Knowledge,Skills, andAbilities:

• KnowledgeofTohonoO'odhamtraditions,language,history,geography,and culture.
• Comprehensiveknowledgeoffederalandstateregulatorylawswith regardtohealthcare deliverysystemsandcompliance,g.Privacy Actof1974,HIPAA, Joint CommissiononAccreditationofHealthcareOrganizations(TJC), etc.
• Comprehensive knowledgeofrelevantlaws,regulationsandpoliciesas theyrelatetoPatientFinancialservices program andpracticesandcompliancewiththird-partymedicalbillingandcollectionsrequirements,includingtherequirementsfortheCentersofMedicareandMedicaidServices andotherprivatepayersofmedicalservicesandgoods.
• Knowledgeofthestandardsandprinciplesofpatientaccountmanagementrequirementsincluding administrative practicesandprocedurescommonto healthcare deliverysystems.
• Knowledgeofandskillintheuse ofpersonalcomputers,varioussoftwareandrelatedcomputerequipmentrequiredto maintaindatabases,preparereports,andtrackprogram activities.
• Knowledgeandabilitytoproperlyutilize,implement,andteachtheuse ofelectronicdata collection.
• Knowledgeofdatacollectionandanalysistechniqueswithability toformatreportsusingdata,withgraphsandtending interpretation.
• Excellentoraland written communication.
• Stronginfluencingandperseverancein investigating.
• Possesstheabilitytoestablishcoordinationwith themedical stafftoeffectchangetomeetregulatoryrequirementsfor TONHC.
• Abilitytoextractappropriate informationfromvarioussources toanalyzedata andreportstoidentifyhigh risk areasandrecommendcorrective action.
• Ability tomediate varyingviewsofprogramrequirementsandobtainconsensusinacceptingconcepts,plansandspecificationstomeetthe needsofthe TONHC.
• Ability to read,interpretandcommunicate complexfederalregulationsandlegal documents.
• Abilityto writeclear,concise reports,businesscorrespondenceand procedures.
• Ability toutilizeorganizationandanalytical skills.
• Abilitytoworkwellbothindependentlyandwithothersin a matrix organization.
• Ability to effectivelypresentandrepresenttheorganization'sinterestexternallywith regulators.
• Ability toeffectivelypresentinformationandrespondtoinquiriesfromemployees,regulatoryagencies,and others.
• Ability to initiateadministrative activitiesas necessary,andinstitute qualitycontrol procedures.
• Abilityto meetdeadlinesandadjusttochangesinorganization'spolicies,procedures,and priorities.

Minimum Qualifications:

• Bachelor'sDegreeinHealthCare Administration,HealthcareLaworclosely relatedfield,and
• Twoyears'experience,education,ortraining,involvingprinciples,techniquesandacceptedpracticesofhealthcarecompliance work.

Licenses, Certifications, SpecialRequirements:

• HealthcareComplianceCertificationisrequiredormustobtainwithinoneyearof employment.
• Experienceinthepreparationoftechnicalreportsonqualitylevelstoidentifyspecific problemareasandtorecommendcorrectiveaction,preferred.
• Relevant experiencein a NativeAmericancommunity, preferred.
• ExperiencewithRPMS andIHSEHR, preferred.
• Mustpossessandmaintaina validdriver'slicensewithnoDUI'sormajortrafficcitationswithinthe last three years.
• Ability to meettheNation'stribalemployer'sinsurance requirements.
• Upon recommendationforhire a criminalbackgroundandNationalFBI check isrequiredtodeterminesuitabilityfor hire.
• TribalpreferenceandNativeAmericanpreferenceshallapplytoall positions.
• Basedonthedepartment'sneeds,incumbentsmayberequiredtodemonstratefluencyinboththeTohonoO'odhamandEnglish language as a conditionof employment.

Physical Demands:

Workissedentarywithsomewalking,bending,stooping.Theworkmayrequirelongperiodsofsittingandoperatinga personalcomputer.Standingforseveralhoursmayberequiredwhenconductingtraining sessions andworkshops.Workareasareindifferentgeographicareas(SellsHospital,SanXavier,SantaRosa,andSanSimonHealthCenters).Theincumbentmustworkat allareason a frequent basis.

WorkEnvironment

Workisperformedina typicalofficesetting.Workisprimarilysedentary,althoughsomephysicaleffortmayberequired.Incumbentisrequiredtooperate a governmentvehicleintheperformanceofassigneddutiesunder avarietyofroadandweatherconditionsandmaintain a validstatedriver'slicense.

Thislistofdutiesandresponsibilitiesis illustrativeonlyofthetasksperformedbythispositionandisnotall inclusive.