Job Code: 03192-70593
At North Suburban Medical Center, you'll find that caring extends to both our patients & our people. Are you looking for an employer with many different career options & a people-focused culture? You've come to the right place. We are committed to each other because when we join together, our patients are cared for in the safest & most compassionate way. Weâ€™re proud of our focus on quality & patient safety. We were named the first hospital in Colorado to receive Joint Commission's Sepsis Certification. This is one of many distinctions that set us apart from other hospitals in the area. We focus on keeping benefits fair, smart and competitive with a full package or rewards that support your health, life career and future.
Above all else, we are committed to the care and improvement of human life. We treat all those we serve with compassion and kindness. If you love the idea of serving a close-knit community of families and friends and are looking for a place to spend your career practicing highly personalized medicine, we invite you to join North Suburban Medical Center.
Manages implementation and ongoing operation of HCAâ€™s Ethics and Compliance program for North Suburban Medical Center. Provides orientation for new staff to ensure compliance with HCAâ€™s Ethics and Compliance policies and procedures. Responsibilities include overseeing Facility compliance with policies and procedures, accreditation standards and state and federal law, conducting investigations, monitoring audit results, providing new employee orientation, chairing the Facility Ethics and Compliance Committee, drafting and managing facility contracts and administration of the clinical research approval process.
Job Responsibilities & Job Knowledge:
Meets the expectations and assumes accountability for all on-going job responsibilities. Balances unexpected tasks while performing on-going responsibilities under ordinary direction and minimal supervision. Current and proficient on job-related knowledge, skills, and industry changes. Demonstrates understanding of job relative to Hospital Operations.
1. Oversees and implements the facilityâ€™s Ethics and Compliance Program and compliance with requirements of the Federal health care programs and the CIA:
a. communicating compliance standards and distribution of policies and procedures to the appropriate facility personnel
b. distributing the Code of Conduct and overseeing related training
c. coordinating and monitoring required compliance training
d. advising colleagues on ethics and compliance matters
e. conducting and cooperating with investigations
f. ensuring no retaliation for good faith reporting
g. coordinating and supporting corporate monitoring and auditing procedures
h. reviewing internal audit reports and investigative reports
i. identifying trends related to ethics and compliance within the facility
j. coordinating with the facilityâ€™s clinical ethics committee
k. overseeing facility compliance with records retention requirements
l. ensuring employee evaluation includes an ethics and compliance component
m. submitting quarterly reports to the Corporate Ethics and Compliance Department
2. Drafts and manages physician and provider contracts to meet facility need and in accordance with the expectations of corporate legal counsel.
3. Coordinates and Supports Corporate Monitoring and Auditing Procedures: Involvement in monitoring and auditing activities such as reviewing internal and external audit reports, reviewing responses to reports to ensure the adequacy of corrective action plans, monitoring billing irregularities/ensuring timely repayments and participation with the Facility Billing Compliance Audit Committee.
4. Chairs the Facility Ethics & Compliance Committee (FECC) to assist in accomplishing the ECO Duties and Mission. Conducts regular and effective FECC meetings.
5. Actively participates in department and hospital strategic planning and effectively implements new program and services.
6. Performs routine managerial duties (process payroll, manage department expenses, participate on hospital committees, process employee evaluations, manage personnel issues.) in an effective and timely manner in order to meet the needs of the department an organization.
7. Ensures compliance with JCAHO standards, federal, state and local regulatory guidelines.
8. Attends in-service presentations and completes mandatory education, including but not limited to infection control, patient safety, quality improvement, MSDS and OSHA standards.
9. Performs other duties as assigned.
Fiscal Responsibility : Consistently, accurately, and completely performs all job responsibilities. Efficiently demonstrates cost consciousness by organizing work processes within established deadlines, and using supplies, equipment, and time according to budgetary guidelines.
1. Accountable for monitoring statistics for budget analysis and implements changes in response to trends.
2. Participates in the selection of sources of needed services not provided by the hospital or department.
3. Continually seeks opportunities to build revenue base and decrease costs while maintaining quality.
Problem Solving/Judgment: Assumes accountability for identifying problems and issues, generating solutions, and anticipating effects of decisions.
1. Analyzes systems and implements appropriate system changes that enhance healthcare services and delivery.
2. Receptive to change or new ways of doing things.
3. Exercises professional judgment when addressing problems as evidenced by a satisfactory resolution (approaches problem with systematic and critical thinking, utilizes appropriate resources, maintains a positive attitude, and involves leadership when needed).
4. Effectively responds to issues/problems pertinent to departmental services that effectively meet the needs of the customer and staff.
Communication: Consistently provides accurate and timely information while listening effectively. Using positive communication skills, shares information clearly and concisely. Proactively disseminates information to keep others informed on key issues and situations.
1. Communicates necessary information to managers in a timely manner.
2. Interacts and communicates with peers and administration in a way that promotes a harmonious and cooperative working environment.
3. Communicates plans for implementation of goals and objectives.
People Leadership: Leads, coaches, develops, and recognizes staff to maximize performance.
1. Models the leadership values of the Company, encouraging a climate of ethical sensitivity and compliant activity, reinforcing the Companyâ€™s commitment to allow employees to report ethics or compliance concerns without fear of retaliation and involving colleagues in meaningful roles in the Ethics and Compliance Program.
2. Provides supervision, leadership, and direction to staff in a manner which fosters a positive, productive work environment.
3. Completes performance evaluations within established deadlines.
4. Provides opportunities for and supports staff career development.
5. Assures the qualifications and competence of departmental staff through validation of licenses, certification, education, training and competencies.
6. Pursues opportunities for personal development and increased management expertise in addition to improvement in technical proficiencies.
7. Actively participates in customer service initiatives.
Bachelors degree required; advanced degree preferred.
Minimum of three years in health care setting; experience with compliance programs and requirements.
Strong implementation skills; knowledge of health care legal and regulatory requirements; strong leadership and presentation skills.
Degree of Supervision Required:
Involves general guidance and direction by the Chief Executive Officer. Employee will be expected to perform most job duties independently and in accordance with established departmental and hospital policies and procedures.
Minimum of three (3) months. May be modified at the discretion of the manager. HCA â€" Corporate Ethics and Compliance training is prerequisite.
Last Edited: 04/13/2018