Job Details

Description

SUMMARY OF DUTIES

The Compliance Specialist is responsible for planning, supporting, and implementing Compliance, Risk Management, and Environment of Care programs for the organization. The individual collaborates with service line directors and managers in all departments to ensure internal compliance with regulations and policies. The position participates in external audits and surveys (e.g., OSHA, HIPAA, Department of Health, Joint Commission) and serves as the primary contact for reporting liability-related situations. Key responsibilities include resolving risk management issues, conducting ongoing assessments of potential liabilities, assistance with safety programs and delivering education on compliance and risk topics.

EDUCATIONAL REQUIREMENTS

Bachelor's degree in healthcare administration, public health, law, business administration or a related field, or equivalent professional experience in healthcare (pre- and post-acute based services preferred)

OTHER (SPECIFIED):

• Notary Public a plus
• Certified Healthcare Compliance (CHC), preferred

Requirements

EXPERIENCE & OTHER QUALIFICATIONS

• Minimum 3 years' experience in healthcare compliance, administration, or risk management.
• Experience working with government agencies or regulatory bodies a plus
• Experience with internal audits and investigations
• Experience creating policies, procedures, and training materials
• Knowledge of medical coding, billing practices, and reimbursement processes
• Strong familiarity with healthcare laws and regulations, including but not limited to HIPAA, ACA, Medicare and Medicaid
• Understanding of accreditation standards (i.e. Joint Commission)
• Knowledge in Safety Management, safety and occupational health regulation, and staff education programs.
• Familiarity with compliance management systems and healthcare information technology.
• Strong familiarity with healthcare laws and regulations, including but not limited to HIPAA, ACA, Medicare and Medicaid.
• Must be able to work and communicate with people at all levels of the organization.
• Requires contacts both inside and outside of all organizational levels.
• Requires considerable tact, discretion and persuasion to obtain results.
• Experience with real estate management and paralegal background a plus.
• OTHER DUTIES AS ASSIGNED

• Performs regular compliance audits and risk assessments to identify and mitigate areas of concern.
• Maintains logs of compliance incidents and prepares reports for senior leadership and regulatory agencies.
• Oversees compliance with data privacy regulations, ensuring the protection of patient health information (PHI).
• Collaborates with IT and security teams to safeguard electronic health records (EHR's) and other sensitive data.
• Acts a subject matter expert on healthcare compliance standards, including but not limited to HIPAA and Stark Law.
• Manages the organization's whistleblower program, ensuring protection for individuals who report concerns.

• Responsible for coordination and oversight of the system-wide Emergency Preparedness and Disaster Plan.
• Maintains documentation related to the safety function, including Joint Commission, OSHA, DOH and applicable regulatory agencies.
• Develops safety policies and procedures and maintains documentation related to safety functions.
• Drafts and maintains organization-wide compliance policies and procedures to ensure adherence to applicable laws and regulations. Conducts regular reviews and updates of compliance documents to reflect regulatory changes.
• Develops and deliver training programs for staff on compliance-related topics, including confidentiality, privacy and ethical practices.

• Reviews all tenant leases and makes recommendations whenever appropriate.
• Meets all prospective tenants and ensures application for tenancy/occupancy is completed and credentials are processed.