Job Description
Job Duties 1. Compliance Officer's primary responsibility is design, implementation and effective operation of the
compliance program.
2. In carrying out policies and responsibilities of the office, Compliance Officer:
•Have direct access to CEO and Board of Trustees.
•Not be subordinate to financial business office director/manager.
•Have authority to investigate compliance violations and act as needed.
•Have access to all needed information, including contracts, billing records and contractual arrangements.
3. Board of Trustees will provide oversight of Compliance Officer's activities.
4. Compliance Officer provides updates on a regular basis to CEO and Board of Trustees on progress of
implementation and improvement of the compliance program.
Procedure 1. Oversee and monitor design, implementation and improvement of the compliance program in light of
changes in regulatory and legal environment and conformity to ethical standards.
2. Be responsible for developing, coordinating and participating in a multifaceted compliance education and
training program that ensures all employees and affiliated parties are educated about Code of Conduct,
corporate compliance program and other specific issues deemed necessary.
3. Ensure independent contractors and agents who furnish services are aware of requirements of the
compliance program with respect to coding, billing and marketing, among other things.
4. Coordinate personnel issues with Human Resources to ensure List of Excluded Individuals and Entities,
General Services Administration Debarment List and National Practitioner Data Bank have been checked
with respect to all employees, medical staff and independent contractors.
5. Work with CFO in periodic reviews, ongoing monitoring and evaluation of regulatory compliance in all
business activities, and recommend development of internal systems and controls to reinforce compliance in
those areas.
6. Independently investigate and act on matters related to compliance, ensuring corrective actions are taken
where compliance failures have been identified.
7. Develop and manage Hotline system and other feedback mechanisms that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.
8. Be responsible, together with Audit and Monitoring Committee, to implement all necessary actions to ensure
achievement of objectives of an effective compliance program by means of review, relevant training, system
of consistent enforcement of rules and development/implementation of corrective action plans.
9. Work with Board of Trustees in consultation with outside legal counsel in reviewing and updating Code of
Conduct to ensure its continuing currency and relevance in providing guidance to management and
employees.
10. Develop, maintain and revise compliance policies and procedures for general operation of the program and
related activities to prevent illegal, unethical or improper conduct. Revise/update as needed.
11. Oversee and manage performance of the compliance program and identify potential areas of compliance
vulnerability and risk and provide specific direction for resolution of problematic issues, as well as general
guidance on how to deal with similar situations.
12. Prepare periodic reports and evidence for Board of Trustees on progress and effectiveness of compliance
activities and efforts.
13. Develop and oversee a system for uniform responses to violations of rules, regulations, policies, procedures
and Code of Conduct and ensure proper reporting of potential violations of law to duly authorized law enforcement agencies.
14. Establish audit controls and measurements to ensure correct processes are in place.
15. Maintain a working knowledge of relevant issues, laws and regulation through periodicals, seminars, training
programs and peer contact.
16. Respond appropriately if a violation is uncovered, including direct report to Board of Trustees or external
agency, if deemed necessary.
17. As part of ongoing auditing and monitoring, Compliance Officer arranges for periodic independent evaluation
of effectiveness of the compliance program.
18. Performance of other duties as may be assigned from time to time.
HIPAA Compliance The Hospital will train Compliance Officer on all aspects of Healthcare Insurance Portability and Accountability
Act (HIPAA). Compliance Officer will adhere to all security and patient confidentiality rules and regulation
mandated by federal government and State of Mississippi. Upon commencement of employment, employee
must sign a Patient Confidentiality and Security Agreement and abide by the Hospital's Confidentiality, Privacy
and Security Policies and Procedures. Failure to adhere to HIPAA standards, Hospital's Security and
Confidentiality Policies and those set forth by federal government and State of Mississippi will result in
disciplinary action up to and including termination.
Qualifications: Education: Doctor of Jurisprudence (JD) or equivalent degree or corporate compliance certification.
Experience: Five (5) or more years of experience desirable.
Supervised by: Administrator/CEO and reports directly to Board of Trustees.
Workers Supervised: Compliance Audit and Appeals Department. OCH Regional Medical Center
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