Compliance Officer

Job Description Job Description Compliance Officer - $75,863.00 - $87,250.00 Reports to: Director of Quality & Compliance POSITION SUMMARY : Reporting to the Director of Quality and Compliance, the Compliance Officer oversees compliance, risk management, contracting activities, and consults around health information management and information security and serves as BNHC’s HIPAA Privacy and Security Officer, Risk Manager and ADA Officer.

Working alongside a full Quality and Compliance team (Quality Improvement and Quality Assurance Managers and Quality Coordinator), the Compliance Officer serves as the subject matter expert, consultant, and trainer on all compliance-related activities within the organization to promote and support a culture of regulatory compliance and patient and staff safety. RESPONSIBILITIES : Develops, implements, and maintains policies, procedures, and protocols to ensure compliance with all federal, state and local regulations, as well as accreditation standards (ex. HRSA, FTCA, The Joint Commission) and ensuring written practice standards and procedures to reduce BNHC’s vulnerability to liability, fraud, and abuse.

Oversees tracking of policies and procedures required by HRSA, Joint Commission, Massachusetts Department of Public Health, and all other regulatory entities. Prepares all documentation and audits internal policies and procedures to promote compliance with those internal policies and external regulations regarding areas of risk management responsibility, including but not limited to sentinel events and root-cause analyses. In collaboration with the Quality Assurance Manager and QA Coordinator, conducts regular audits, tracers, risk assessments and mock surveys to identify compliance risks and implements corrective actions as needed.

Stays informed about changes in healthcare regulations, guidelines and best practices and ensures that policies are procedures are updated accordingly. Serves as one of the primary points of contact for regulatory agencies, auditors and accrediting bodies, ensuring timely responses to inquiries and requests for information. Prepares and (as needed) presents reports on compliance activities, trends and outcomes to senior leadership and governing bodies.

Prepare and supports Director of Quality and Compliance in reporting to the Board of Trustees as specified in the Corporate Compliance and Risk Management Plans regarding implementation of the plans. Supports the Director of Quality and Compliance in ensuring that the Board of Trustees and management have the necessary information and guidance to approve controls to measure and manage risk across the health center (ex. Risk in financial operations, risk of adverse outcome for patients, and risk in data). Works closely and collaboratively with IT/systems to ensure that data and technology are supporting the risk reporting process.

Coordinates risk management functions daily to maximally ensure that identification of risk exposure, assessment, appraisal, and loss prevention are carried out, so that the institution remains safe for its patients, families, and employees. Identifies and limits legal exposures. Along with the Director of Quality and Compliance, is responsible for the handling and defense of legal claims.

Responsible for the coordination, management and processing of all claims-related activities (health related claim, including medical malpractice that may be eligible for FTCA coverage, as well as commercial liability and/or employment claims) daily and serves as the claims point of contact. and/or employment claims.

Responsible for ensuring the preservation of all BNHC documentation related to any actual or potential claim or complaint (including issuing, reissuing and all education related to Litigation Holds) Responsible for ensuring that all notifications of intent to sue or other service-of process/summons that BNHC or its providers receives related to any alleged claim or complaint are promptly sent to the HHS Office of General Counsel General Law Division. Responsible for working in full cooperation with the HHS Office of General Counsel General Law Division or if deemed covered, the Department of Justice attorneys, who are assigned the case to defend.

This includes serving as primary point of contact for all document production required throughout litigation. Serves as primary point of contact with brokers and gap carriers to ensure timely filing of potential or actual claims. Develops statistical and qualitative reports on risk management trends and patterns and communicates this information effectively.

Participates in Patient Review Committee, which reviews all patient behavioral incidents/situations that may trigger a health center intervention, warning letter or discharge. Supports the Director of Quality and Compliance and Quality Assurance Manager in leading readiness teams for planned accreditation or licensure inspections and is responsible for completing and submitting new and renewal applications for licensure. With support from the Director of Quality and Compliance, the Compliance Officer prepares the annual deeming application for Federal Tort Claims Act coverage.

Ensures that any corrective actions are remediated and resubmitted to HRSA within the timeframe specified to prevent conditions on grantee award. Provides or arranges for training and education to all BNHC staff to ensure that the health center is compliant with laws, standards, and regulations of the state, federal, FTCA, Joint Commission and all other regulatory agencies. Serves as compliance subject matter expert on special projects of strategic significance, as assigned by the Director of Quality and Compliance.

This may include serving in a consulting role for departments working on process improvement, supporting the startup of a new service or site, or other projects offering necessary compliance/regulatory support as requested. Serves at BNHC’s HIPAA Privacy and Security Officer, overseeing and managing the development and implementation of BNHC’s Privacy Rule Compliance program. Serves alongside the Controller, the CFO and the Director of Pharmacy to audit compliance with BNHC’s 340b program.

Ensures that Policies and Procedures associated with 340b compliance are up to date. Performs other duties as required. QUALIFICATIONS: Requires a master’s degree (preferably in health administration or business) plus extensive knowledge of management and community health center compliance.

Commitment to the Mission and Values of Brockton Neighborhood Health Center and the communities with serve. PROFESSIONAL BEHAVIOR: Maintains leadership skills in a professional and objective manner.

Demonstrates responsibility and accountability. Maintains confidentiality at all times. Maintains discretion of conversation in work areas.

Is pleasant, courteous, and considerate of patients, staff, and external contacts. Demonstrates ability to prioritize demands, work with distractions, adapt to change, exercise efficient time management, and work independently. Maintains appropriate chain of command.

Participates in continuing education for personal and professional growth. COMMUNICATIONS: Strong professional verbal, written and interpersonal communication skills required. Must regularly communicate relevant information learned from other managers and from various meetings with staff.

This can be accomplished via regular staff meetings, departmental e-mails, memos, or communication with individual staff members. Communication with supervisors and management must also routinely occur. PHYSICAL REOUIREMENTS : Mostly sedentary with some walking between offices.

Physical dexterity and vision suitable to accomplish the job duties outlined above. The ability to lift as much as 20 pounds may be necessary. About us : BNHC is a multicultural organization that collaborates with community agencies and residents to provide high quality comprehensive health care.

We are committed to health promotion and disease prevention. BNHC began providing services in 1994 in a mobile medical van operating out of a church parking lot. Since then, the center has rapidly grown to provide desperately needed services to low-income and marginalized populations in the greater Brockton area.

BNHC is committed to providing care that is responsive to community health needs and is linguistically, culturally and financially accessible. BNHC serves an extremely diverse patient population including Brazilian, Cape Verdean, Haitian, Latino, Portuguese, African American and Caucasian, 77% of whom live in poverty. BROCKTON NEIGHBORHOOD HEALTH CENTER, INC. does not discriminate in hiring or employment on the basis of race, color, religion/creed, national origin, ancestry, age, gender, transgender status or gender identity, sexual orientation, legally recognized disability, veteran, military or military reserve status, HIV status, genetic information, or any other legally protected class.

No question used on this application is intended to acquire information to be used for such discrimination. BNHC is committed to providing a safe and heathy environment for patients and staff. As a condition of employment, employees, to include new hires, are required to be fully vaccinated to include the most recent COVID 19 booster and annual flu vaccines, with the exception of those who have documented medical or religious exemptions, that must be approved by BNHC according to its protocols.

Additional vaccines may be required based on the recommendation of the CDC. New hires who are not yet vaccinated for flu or COVID can arrange to be vaccinated on site. .