JOB PURPOSE: The Director of Compliance, as an integral part of the Compliance team and is responsible for the operational administration and implementation of a comprehensive Compliance Program to identify and mitigate the potential for risk across the organization. In this role, the incumbent provides leadership, direction, and oversight to the El Rio Health Compliance Program. Monitors and reports results of compliance efforts, audits and investigations to the Chief Compliance and Risk Officer (CCRO) and implements all necessary actions to ensure achievement of the objectives of the Compliance Program. Actively oversees and manages and contributes to the development and implementation of the Health Information Management (HIM) program. Works collaboratively with clinical leaders, key administrative leaders, and frontline staff to identify and reduce risk for participating in non-compliant actions across the organization. Reports risk reduction efforts to the Corporate Compliance and Risk Committee as needed, and the CCRO.

The Director of Compliance is a leadership role that requires independent decision-making and proactive monitoring of compliance. The Director of Compliance is responsible for implementing and managing the organization’s compliance programs, which includes developing policies, conducting training, and maintaining processes to guarantee the organizations’ adherence to industry regulation, compliance policies and procedures and to ensure that such policies and protocols are following federal, state and local laws and regulations, including requirements of external funding, regulatory and accreditation agencies. In addition, the Director of Compliance performs compliance assessments, assists with the creation of an annual work plan, and provides guidance on compliance matters both internally to other departments and externally.

The Director will assess compliance issues, draft key documents, and present clear recommendations to CCRO. The Director serves as a resource for staff and compliance issues and ensures the ability of all employees to raise questions of compliance. The Director works with other leaders to ensure compliance within all El Rio Health departments to promote the mutual mission to promote and ensure adherence to all regulatory and industry requirements, as well as administrative or organizational policies. The Director of Compliance works with minimal administrative supervision and review and has independent decision-making authority for resolution of normal or operational work problems within the scope of authority and responsibility for the position.

The primary goal of the El Rio Health Director of Compliance is to support El Rio’s Mission of providing comprehensive, quality health care that is affordable and accessible to all who may have healthcare needs, by successfully performing the primary essential functions.

Essential Job Functions:

1. • Evaluates new and existing services and procedures to determine if they present a compliance risk to the organization and assists with countermeasures to improve the service in cooperation with the Chief Compliance and Risk Officer.
   • Investigates compliance concerns for severity, frequency, and probability of financial loss, and reports as necessary to appropriate administration, committees, and personnel.
   • Completes an incident for compliance concerns and investigates and establishes a plan that may include policies, educational programs, and reporting methods for the appropriate areas. Directs information on incidents as appropriate to staff. Uses industry benchmarking to compare appropriate data.
   • Participates in routine rounding, tracing, and monitoring of all clinical areas to identify and remediate areas of compliance nonadherence.
   • Identifies through the review of events, problems, patterns, and trends that reflect opportunities for correction, prevention, and improvement.
   • Develops and implements a comprehensive program to respond to any legal inquiries related to patient grievances or quality of care concerns filed with state medical, dental, pharmacy, behavioral health, or nursing boards. Trains and assists staff in responding to all state boards inquiries.
   • Demonstrates and role models behavior regarding proper customer satisfaction, conduct, confidentiality, complaint resolution, and problem solving.
   • Provides compliance education for the leadership team, professional staff and employees concerning methods for decreasing compliance risk.
   • Adheres to El Rio Health organizational and department-specific safety, confidentiality, values, policies, procedures, and standards.
   • Reviews the Compliance Plan annually and makes recommended changes with updates to compliance policies and procedures as required.
   • Assists and helps to establish strategic goals for compliance by gathering pertinent business, financial, service, and operational information. Identifies and evaluates trends and options, chooses a course of action, and evaluates outcomes related to compliance.
   • Prepares activity reports and updates to inform management of the status and implementation and goal achievement related to the Compliance Plan.
   • Establishes work schedules and assignments for staff, according to workload, space, and equipment available.
   • Completes responses to external audits including but not limited to First Tier Downstream Related Entities (FDR) audits from contracted health plans.
   • Conducts periodic compliance risk assessments; identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future; produces written reports based on audit and risk assessment findings and remediation progress.
   • Collaborates with Human Resources and other departments to develop and maintain the organization’s policies and procedures.
   • Responds to alleged violations of rules, regulations, policies, and procedures by evaluating or recommending the initiation of investigative procedures. Acts as an independent reviewer to ensure that compliance issues/concerns within the organization are being appropriately investigated and resolved.
   • Monitors and coordinates compliance activities of the organizations. In conjunction with the Chief Compliance and Risk Officer investigates/resolves difficult compliance concerns and recommends action plans to address recurring issues.
   • Works with Human Resources and health center leadership and others as appropriate to develop and carry out an effective compliance training program including appropriate introductory training for new employees as well as ongoing training for all employees and managers.
   • Supports health center requests for guidance on compliance issues.
   • Develops guides and resources on compliance topics and provides training, knowledge, and skills to staff.
   • In collaboration with the Chief Compliance and Risk Officer/HIPAA Privacy Officer, oversee, update, develop, and implement compliance policies and procedures.
   • In concert with the Chief Compliance and Risk Officer/HIPAA Privacy Officer will be responsible for all duties associated with HIPAA compliance, including the investigation of, and reporting of HIPAA violations and the composition and delivery of responses to state regulatory agency complaints and inquiries.
   • Assists in leading in the organization’s efforts for the HRSA On-Site Visit, including gathering documents, ensuring reviews and approval of policies and procedures.
   • In collaboration with the Chief Compliance and Risk Officer/HIPAA Privacy Officer and investigator, review HIPAA regulations for technology management and participate in conducting required controls, including periodic Risk Assessments.
   • Ensures that the HHS OIG's List of Excluded Individuals and Entities and the General Services Administration's (GSA's) List of Parties Debarred from Federal Programs have been checked with respect to all employees, provider staff, and independent contractors, and vendors.
   • Assists the Chief Compliance and Risk Officer with monitoring of the Compliance Hotline and independently investigates allegations of noncompliance and monitors appropriate corrective action and/or subsequent compliance.
   • Serves as the Vice Co-Chair of the Corporate Compliance and the Risk Management Committee.
   • Conducts an annual enterprise compliance risk assessment for the organization.
   • Implements and monitors corrective action plan and/or subsequent compliance developed after compliance investigations.
   • Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position.
   • Demonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.
   • Accomplishes department objectives by managing assigned staff; planning and evaluating department activities.
   • Supervises, plans, organizes, and over sees operations for assigned areas. 
   • Serves as a resource to assigned staff regarding specific skill demonstration, promotion of knowledge and communications.
   • Establishes, communicates, and develops means to implement standards of expectation, performance, and behavior for assigned department(s).
   • Achieves and maintains departmental compliance with all relevant legal and regulatory standards and expectations.
   • Maintains knowledge of current trends and developments.
   • Monitors health information management systems, services, and staff performance to ensure data quality and integrity.
   • Provides education and training to health center staff in areas relevant to policies and procedures.
   • Identifies and analyzes the design of jobs, work processes, workflows for assigned staff/departments and implements appropriate changes to improve effectiveness, efficiency, and productivity to support the overall goals of the organization.
   • Serves on standing and ad hoc medical, administrative, and department leadership committees, and serves as a resource to other departments to resolve problems that arise both within and outside of assigned staff/departments.
   • Reviews, evaluates, and updates departmental position descriptions, policies, and procedures annually as necessary to comply with regulatory, licensing, accrediting, and HIPAA requirements.
   • Serves as a resource to supervisory staff regarding specific skill demonstration, promotion of knowledge and communications.
   • Establishes, communicates, and develops means to implement standards of expectation, performance, and behavior for assigned staff/departments.
   • Achieves and maintains departmental compliance with all relevant legal and regulatory standards and expectations and incorporates knowledge of current trends and developments.
   • Oversees the management and security of patient health information, ensuring compliance with federal, state, and local regulations.
   • Develops and implements policies and procedures to ensure efficient operations and high-quality service.
   • Manages the selection, training, and evaluation of leadership/supervisory staff, fostering a collaborative and productive work environment.
   • Coordinates with IT department to oversee the implementation and maintenance of electronic health record (EHR) systems, ensuring system reliability and accessibility for authorized personnel.
   • Conducts regular audits of processes to identify areas for improvement and ensure compliance with changing healthcare laws and regulations.
   • Represents assigned department(s) in interdisciplinary committees within the healthcare facility, contributing to policy development and strategic planning initiatives.
   • Leads compliance monitoring to identify process gaps, validate compliance levels, map processes, draft corrective actions/remediation plans, oversee implementation of corrective actions, prepare reports/presentations.

Minimum Education and Experience:

• Bachelor’s degree in business administration, healthcare administration, health Information management or a related field from an accredited college or university.
• Seven (7) years” supervisory experience; preferably in a healthcare environment.
• Seven (7) years progressive experience in a leadership role performing Compliance or Health Information Management or auditing functions, analysis, and reporting in a healthcare environment.
• Coursework in ethics, regulatory affairs, health information, and corporate governance.
• Proficient in the use of Electronic Health Record and Microsoft Office products.

If applicable, an equivalent combination of education and experience may be considered and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations:

• Certification in Healthcare Compliance (CHC) or Compliance and Ethics Professional (CCEP) is preferred or obtained within the first year of employment.
•  Level I fingerprint clearance card: current valid and in good standing or have applied for it within seven working days after beginning employment.
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday. If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities:

•   Master’s degree in healthcare related professional field from an accredited university.
•   Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) credential.
  • Current Registered Nurse License in good standing from the Arizona Board of Nursing or other advanced level clinical healthcare professional field.
  • Three (3) years’ nursing experience for candidates as applicable.
•   Bilingual (English/Spanish) with the ability to speak, read and write in both languages.

El Rio Health is a diverse and inclusive organization. We are invested in helping you and your family Create Tomorrow.

 Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 El Rio Health does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age 40 and over, disability, genetic information, military status, ancestry, marital status, familial status, or any other status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

 El Rio Health requires all employees (except those 100% working remotely) to have a Level One Fingerprint Clearance card. A.R.S. 36.425.03. If the prospective employee does not possess this prior to hire, fingerprint application must be completed within 7 days post hire.

 All employees are strongly recommended to obtain COVID 19 and maintain vaccination status (i.e. as recommended by CDC and/or other public health agencies) to include an Influenza vaccination. Personnel who decline to receive COVID 19 and/or flu vaccination per most recent CDC recommendations will be recommended to wear a facemask while in an El Rio Health facility, including both clinical and non-clinical areas from November 1 to April 30 (subject to change depending on viral activity). Subject to exemptions and accommodations when required by law.

 All employees are required to undergo drug testing prior to employment and, will be subject to post-accident, reasonable suspicion, return to duty and follow up drug and alcohol testing in compliance with Federal and State regulations for alcohol and controlled substance testing. Employees in positions holding responsibility for the safety and welfare of others will also be classified as safety sensitive.

 El Rio Health is a non-profit 501(c)(3) Federally Qualified Health Center (FQHC) and abides by all applicable federal Drug-Free Workplace standards. El Rio Health is an equal opportunity employer.