Position Summary: 

Working with the Senior Director to develop, implement, and monitor an enterprise‐wide compliance and audit program that promotes a corporate culture of ethical and compliant behavior in keeping with federal and state regulatory requirements Assists in communicating the compliance and audit program to executive management and the Board of Directors Responsibilities also include conducting internal audits for the purposes of monitoring and detecting noncompliance with applicable laws and regulations, the design and implementation of education programs addressing compliance and The Guthrie Clinic Code of Conduct, the development of  compliance and privacy related policies and procedures, the investigation and status reporting of compliance and privacy concerns/issues, and the supervision of clinical coders who perform compliance audits of clinical documentation, coding, and billing.

Education, License & Cert: 

Bachelor's degree, BS or BA in a healthcare, administration, accounting or related field

Experience: 

• Three to five years in compliance in a health care organization

• Experience in conducting coding and compliance audits and developing corrective action plans helpful

• Ability to communicate with all levels of management and staff effectively, including report writing skills • Effective time management, flexibility, and prioritization with project management

• Proficient computer skills (Excel, Access, Word, PowerPoint)

• Able to analyze information obtained from the clinical, billing, and financial databases

• Highly self‐motivated individual who works well independently and is able to make decisions and follow through

• Work well under pressure while meeting internal and external reporting requirements and deadlines

• Maintain confidentiality of medical information and other sensitive data

Essential Functions: 

1. Development, execution, and monitoring of the Compliance Program

a. Responsible for the development of an annual audit workplan designed to reduce the exposure of non‐compliant practices throughout The Guthrie Clinic, and provide employees the ability to audit/monitor actions and practices within their own area, department, or entity 

b. Conduct/recommend  internal audits for the purposes of monitoring and detecting noncompliance with applicable laws and regulations

c. When noncompliance is detected, recommend a solution and monitor to ensure that the recommendations have been implemented

d. Facilitate independent audits performed by management or their designee of compliance related activities

e. Formalize and monitor systems to enable employees to report instances of noncompliance or suspicious activity without fear of retribution

f. Ensure the reporting system is publicized and that allegations of noncompliance are investigated and responded to promptly

g. Assess and implement changes on an on‐going basis to improve the prevention/detection of any noncompliance behavior and/or practices

2. Education

a. Develop and coordinate appropriate compliance training and educational programs for all employees, incorporating the organization’s commitment to comply with all applicable laws and regulations, as well as internal policies, procedures, and ethical requirements  

b. Assess the need for additional training and education, with focus on identified high risk areas

3. Communication

a. Responsible for the distribution of information to the appropriate area manager or administrator regarding any non‐compliant behavior or fraudulent practice which may be identified through reports, Hotline/link calls, or audits 

b. Provide resolution follow‐through with appropriate management and/or staff to address the non‐compliant behavior or fraudulent practice ensuring continued adherence to The Guthrie Clinic Code of Conduct

c. Promote a retaliation free internal reporting process, including an anonymous telephone reporting system.

4. Policy and Procedure

a. Develop and implement compliance and privacy policies and procedures designed to promote compliance with the requirements set forth by Federal and State agencies, and prevent illegal, unethical, or improper conduct

b. Revise and distribute the written Code of Conduct and Employee Compliance Handbook which sets forth the ethical principles and policies which serve as the basis of the Compliance program

5. Investigation and Reporting 

a. Conduct, coordinate, or oversee privacy and/or compliance related investigations as appropriate

b. Oversee and monitor, as applicable, implemented corrective actions to compliance and privacy investigations

c. Maintain compliance and privacy report logs on the commencement and outcomes of investigations.

d. Prepare reports/training for presentation to The Guthrie Clinic Audit Committee/ The Guthrie Clinic Board of Directors, and oversight committees detailing compliance initiatives and actions 

e. Ensure proper reporting of violations or potential violations to Senior Management and/or duly authorized enforcement agencies as appropriate and/or required

Other Duties: 

1. Travel is frequently required within Guthrie region and sites

2. It is understood that this description is not intended to be all‐inclusive and that other duties may be assigned as necessary in the performance of this position.

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