Job Summary:
This position serves as a key member of the GPTLHB Executive team is responsible for the management and oversight of the corporate compliance program for GPTLHB, including the Oyate Health Center (OHC). The position ensures the governing body, management and employees are in compliance with the rules and regulations of regulatory agencies, that organization policies and procedures are being followed, and that behavior in the organization meets the company’s Standards of Conduct. This position is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program. This position partners with leaders from the governing body, management, medical and allied staff to ensure compliance and improve consumer care.
Essential Functions:
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Plans, organizes, implements, and monitors the GPTLHB’s compliance program; coordinates related audit and assessment activities, communicates expectations, and reports results.
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Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Program.
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Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
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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.
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Collects, evaluates, and distributes data, and provides reports on a regular basis, and as directed or requested, to keep the governing body, CEO and senior management informed of the operation and progress of compliance efforts.
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Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
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Manages day-to-day operation of the compliance program and internal audit.
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Responsible for the operations of GPTLHB/OHC’s Organizational Integrity Program (OIP) and Internal Audit Function; Develops and implements system-wide OIP and Internal Audit policies & procedures; Oversees the annual Internal Audit Work Plan; oversees and coordinates the development of OIP training and education; coordinates internal audits and investigates reports of integrity matters.
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Reports to the GPTLHB/OHCs Board Internal Audit Committee. Serves on the Human Research Protection Quality Committee, and the Entity Local Integrity Committees.
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Chairs the GPTLHB/OHC Organizational Integrity Committee and the GPTLHB/OHC HIPAA Privacy & Security Committee.
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Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
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Collaborates with other departments (for example, human resources and health information management director) to direct compliance issues to appropriate existing channels for investigation and resolution.
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Consults with general counsel as needed to resolve difficult legal compliance issues.
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Responds to alleged violations of rules, regulations, policies, procedures and standards of conduct by evaluating or recommending the initiation of investigative procedures; Develops and oversees a system for uniform handling of such violations.
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Acts as an independent review and evaluation body to ensure that compliance issues and concerns within the organization are being appropriately evaluated, investigated and resolved.
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Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
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Identifies potential areas of compliance vulnerability and risk, develops and 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.
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Provides reports on a regular basis and, as directed or requested, keeps the Corporate Compliance Committee and senior management informed of the operation and progress of compliance efforts.
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Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate or required.
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Establishes and provides direction and management of the compliance hotline.
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Institutes and maintains an effective compliance communication program for the organization, including promoting a) use of the compliance hotline, b) heightened awareness of standards of conduct, and c) understanding of new and existing compliance issues and related policies and procedures.
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Works with the human resource department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees and ongoing training for all employees and managers.
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Monitors the performance of the compliance program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.
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Assists with and/or at times coordinates investigations to identify root cause analysis of incidents and near misses.
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Provide end-to-end support for Compliance, including consultation, diagnostics, planning, implementation, and evaluation.
Professional Behavior
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Effectively plan, organize workload and schedule time to meet the demands of the position.
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Work in a cooperative and professional manner with OHC and GPTLHB staff.
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Treat Great Plains tribes and collaborators with dignity and respect.
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Utilize effective verbal and written communication skills.
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Advance personal educational development by attending training sessions and seminars as appropriate.
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Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors and guests.
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Foster a work environment of wellness, courtesy, friendliness, helpfulness and respect.
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Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
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Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation and/or personalities.
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Maintain and ensure organizational privacy and confidentiality.
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Handle crisis and tolerate stress professionally.
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Be self-directed and take proactive initiative to assist others.
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Resolve issues with other departments and coworkers without direct supervision if needed.
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Exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
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Promote an alcohol, tobacco and drug-free lifestyle.
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Embrace modes of appearance and attire that reflect a professional presence.
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Adhere to GPTLHB policies and procedures.
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Other duties as assigned by the Supervisor
Requirements
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Participates in Core Connections training and applies GPTLHB Core Connections concepts and practices in their work.
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Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.
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Possess the ability to resolve issues with other departments and coworkers without direct supervision.
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Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
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Ability to maintain a flexible work schedule, including evenings, weekends and overnight or extended travel as necessary.
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Ability to effectively present information in one-on-one and small group situations to community members, consumers and other employees of the organization.
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Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.
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Valid driver’s license must be kept current, and certificates, credentials or licenses must be kept current and consistent with regulations required by applicable federal, state and/or grant regulations.
Controls/Guidelines
The supervisor provides administrative direction with assignments in terms of broadly defined goals or functions.
The employee usually has responsibility for independently planning, designing, and carrying out programs, projects, studies, or other work.
Results of the work are considered technically authoritative and are normally accepted without significant change. If the work should be reviewed, the review concerns such matters as fulfillment of program objectives, effect of advice and influence on the overall program, or the contribution to the advancement of technology. Recommendations for new projects and alteration of objectives usually are evaluated for such considerations as availability of funds and other resources, broad program goals, or established priorities.
Guidelines are broadly stated and nonspecific, e.g., broad policy statements and basic legislation that require extensive interpretation.
The employee must use judgment and ingenuity in interpreting the intent of the guides that do exist and in developing applications to specific areas of work. Frequently, the employee is recognized as a technical authority in the development and interpretation of guidelines, policies and organizational requirements.
Complexity/Scope and Effect
The work includes varied duties requiring many different and unrelated processes and methods that are applied to a broad range of activities or substantial depth of analysis, typically for an administrative or professional field. Decisions regarding what needs to be done include major areas of uncertainty in approach, methodology, or interpretation and evaluation processes that result from such elements as continuing changes in program, technological developments, unknown phenomena, or conflicting requirements.
The work requires originating new techniques, establishing criteria, or developing new information.
The work involves planning, developing, and carrying out vital administrative or scientific programs.
The programs are essential to the missions of the organization or affect large numbers of people on a long-term or continuing basis.
Contacts
The personal contacts are with individuals or groups from outside the organization in a moderately unstructured setting. For example, the contacts are not established on a routine basis and the purpose and extent of each contact is different.
The purpose is to influence, motivate, interrogate, or control persons or groups. The persons contacted may be fearful, skeptical, uncooperative, or dangerous. Therefore, the employee must be skillful in approaching the individual or group in order to obtain the desired effect, such as gaining compliance with established policies and regulations by persuasion or negotiation, or gaining information by establishing rapport with a suspicious informant.
Physical Demands/Work Environment
The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items, such as papers, books, or small parts; or driving an automobile. The employee must be able to read, write, speak and hear.
The environment involves everyday risks or discomforts that require normal safety precautions typical of such places as offices, meeting and training rooms, requiring use of safe work practices with office equipment, avoidance of trips and falls, observance of fire regulations and traffic signals. The work area is adequately lighted, heated, and ventilated.
Supervisory and Management Responsibility
This is a non-supervisory position that may provide functional direction, guidance and instruction to other employees when necessary. This position possess authority to assign, coordinate, and review quality and quantity of work of other employees. Instructs employees in specific techniques or technical methods for accomplishing work assignments. The employee may perform the same type of work as other employees but may be responsible for performance of the more technically difficult, controversial, or sensitive work assigned to the unit or group.
MINIMUM QUALIFICATIONS
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Master’s degree and three (3) years of relevant experience, or bachelor’s degree and five (5) years of progressively responsible relevant experience. The experience required for supervisory/management positions will be inclusive of at least three (3) years of supervisory/management experience.
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This is a senior professional and/or management position that requires post-secondary education and/or considerable experience or a clinical degree requiring a clinical rotation/internship. Individuals must have applicable education and/or experience applying principles, concepts, and methodology of a professional or administrative occupation to permit the independent performance of recurring assignments or carrying out difficult/complex assignments, operations, and procedures; or applicable education and/or experience applying a wide range of technical methods, principles, and practices similar to a narrow area of a professional field such as the design and planning of difficult, but well-precedented projects.