BASIC FUNCTION

Responsible for overseeing the organization's compliance program to ensure adherence to applicable laws, regulations, and ethical standards, the Director of Compliance collaborates with the senior leadership team, develops compliance strategies, and promotes a culture of integrity and ethical conduct. This role requires strong knowledge of healthcare regulations, attention to detail, and a commitment to upholding the highest standards of compliance and ethics.

PRIMARY RESPONSIBILITIES AND DUTIES

Compliance Program (CP) Development and Implementation:

• Develop, implement, and maintain an effective compliance program that aligns with federal, state, and local regulations, as well as FQHC-specific requirements.
• Support the implementation and maintenance of the 340B compliance program, including policy and procedure development.
• Establish policies, procedures, and standards to promote compliance, ethics, and the prevention, detection, and resolution of compliance-related issues.
• Conduct regular assessments of compliance risks, evaluate the effectiveness of compliance controls, and recommend improvements as needed.
• Advise the Chief Executive Officer and/or the HealthPoint Board of Directors regarding rights and responsibilities related to compliance.
• Design and deliver compliance training programs to educate employees on compliance policies, regulations, and ethical standards, including programs specific to support 340B compliance requirements.

Regulatory Compliance and Reporting:

• Monitor relevant laws, regulations, and guidelines to ensure the HealthPoint's compliance in areas such as HIPAA, OSHA, Medicare, Medicaid, and other healthcare regulations.
• Ensure the FQHC's 340B Drug Pricing Program is compliant with federal regulations and guidelines.
• Stay informed about evolving compliance requirements and provide guidance to the organization on necessary adjustments and updates.
• Oversee the preparation and submission of accurate and timely compliance reports, certifications, and disclosures to regulatory bodies, grantors, and other stakeholders, including Compliance Performance Improvement Committee (CPIC), Chief Executive Officer, and HealthPoint Board of Directors.

Auditing and Monitoring:

• Develop and implement a comprehensive auditing and monitoring program to assess the effectiveness of compliance controls and identify potential areas of non-compliance.
• Conduct periodic internal audits and reviews to evaluate compliance with policies, procedures, and regulatory requirements.
• Conduct regular internal audits of the 340B Program to identify and address compliance issues.
• Monitor and analyze 340B purchasing and utilization data to ensure program compliance.
• Prepare and review 340B compliance reports to identify and rectify discrepancies, potential diversion, and duplicate discounts.
• Collaborate with external auditors and regulatory agencies during compliance audits and investigations, providing necessary documentation and support.
• Establish and maintain processes for tracking and resolving compliance-related issues, including the implementation of corrective and preventive actions.

Privacy and Data Protection:

• Oversee the development and implementation of policies, procedures, and safeguards to protect the privacy and security of patient information and ensure compliance with HIPAA regulations.
• Collaborate with the information technology team to implement and maintain appropriate security measures for electronic health records and other sensitive data.
• Respond to privacy and security incidents, conducting investigations, mitigating risks, and implementing measures to prevent future occurrences.
• Provide guidance on the proper handling and disclosure of protected health information (PHI) in accordance with HIPAA requirements.

Ethical Standards and Corporate Governance:

• Promote a cul ure of integrity, ethical conduct, and corporate governance throughout the organization.
• Develop and enforce a code of conduct and ethics that reflects the organization's values and compliance expectations.
• Provide guidance and support to employees, management, and the board of directors on ethical dilemmas, conflicts of interest, and whistleblower protections.
• Establish and maintain processes for reporting, investigating, and resolving compliance concerns and allegations of misconduct.

Training and Education:

• Develop and deliver comprehensive compliance training programs for employees, contractors, and volunteers to ensure awareness and understanding of compliance obligations.
• Stay up to date with emerging compliance trends, best practices, and regulatory changes, and disseminate relevant information to stakeholders.
• Provide guidance and support to department heads and supervisors on compliance-related matters and assist in the development of department-specific compliance initiatives.

Stakeholder Engagement and Communication:

• Serve as the primary liaison with external regulatory agencies, auditors, and grantors on compliance-related matters.
• Foster collaborative relationships with internal stakeholders, including executive leadership, department heads, and staff, to promote a strong culture of compliance.
• Regularly communicate compliance updates, trends, and best practices to the executive team, board of directors, and other relevant stakeholders.
• Coordinate and support compliance-related committees and workgroups, fostering cross-functional collaboration and knowledge sharing.

Compliance Risk Management Collaboration:

• Identify and assess compliance risks facing HealthPoint, taking proactive measures to prevent and mitigate potential risks.
• Collaborate with internal departments, such as legal, finance, and human resources, to ensure integrated risk management and compliance efforts.
• Stay informed about emerging compliance risks and industry trends, providing recommendations and guidance to mitigate potential exposures.
• Support Organizational Compliance with HRSA FQHC Program Requirements.
• Advise the Chief Executive Officer and HealthPoint Board of Directors regarding HRSA FQHC program requirements.
• Develop and monitor an annual HealthPoint Board workplan designed to support compliance with HealthPoint Board governance requirements.
• Review minutes of HealthPoint Board activities to ensure HealthPoint Board authority is adequately documented.
• Support the HealthPoint Chief Human Resources Officer in the annual review of HealthPoint Board membership for compliance with report to the Chief Executive Officer and HealthPoint Board Chairperson.
• Support annual HealthPoint Board conflict of interest screening and attestation of eligibility.
• Coordinate preparation for periodic HRSA operational site visits.
• Performs other duties as assigned.

Effectively carries out tasks and responsibilities beyond core job duties and primary role. The additional duties may vary from time to time and encompass a wide range of activities that contribute to the overall success of the organization (floating, schedule variations, assisting co-workers, patients, visitors, customers, leaders, and other stakeholders in support of the organization.)

LEADERSHIP RESPONSIBILITIES

Provides overall management and direction to Department/Division staff.