Principal authority and responsibility for the development, implementation, oversight, and evaluation of all aspects of Uncompahgre Medical Center’s Compliance Program.

• Oversee and monitor the development and implementation of UMC’s compliance program.
• Direct methods to improve UMC efficiency and quality of services and to reduce UMC’s vulnerability to fraud and abuse, such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing, maintaining, implementing, and disseminating written practice standards and procedures.
• Periodically revise the compliance program, or recommending such revisions, in light of changes in the needs of UMC or changes in the law and/or in the standards and procedures of government and private payor health plans.
• Develop, coordinate, and participate in training programs that focus on the components of the compliance program and seek to ensure all UMC board members, as well as employees, contractors, agents, consultants, volunteers, and others who act on UMC’s behalf are knowledgeable of, and comply with, pertinent local, state, and regulations and standards and the requirements of UMC compliance program.
• Ensure the Department of Health and Human Services, Office of Inspector General’s List of Excluded Individuals and Entities, and the General Services Administration’s Excluded Parties List System have been checked with respect to all board members and staff, as well as all applicants for board or staff membership.
• Investigate, independently or with qualified legal counsel or consultants, and ac on any report or allegation of unethical or improper conduct or business practices, and implement and monitor appropriate corrective action and/or subsequent compliance.
• Direct the implementation of corrective actions in response to reports or findings of potential non-compliance, including conferring with the CEO regarding the enforcement of disciplinary and corrective actions.
• Report information on the activities of the compliance program to the CEO and Board of Directors on a quarterly basis.
• Oversight of UMC Risk Management QA/QI Committee activities.
• Investigate all instances of suspected illegal or unethical conduct and may, upon obtaining appropriate authorization, and consistent with Health Center budget constraints, seek the advice of qualified legal counsel and hire outside investigators and/or consultants with acknowledgment of the Chief Executive Officer.
• Maintain direct access to CEO and the Health Center’s Board of Directors through the CEO unless the matter involves the CEO, in which case the Compliance Officer may report independently to the Board of Directors, and to qualified legal counsel, for the purpose of making reports and recommendations on compliance matters.
• • Receive incident reports through MedTrainer and track the progress ensuring resolution is accurately, appropriately, and timely determined in compliance with state and federal laws.
  • Coordinate and track internal audits, including 340B, inventory, and department-specific audits, to ensure accuracy, proper documentation, and on-time completion.
  • Provide oversight and coordination of internal compliance efforts, including HRSA-required compliance assistance and internal audits such as 340B, inventory, and department-specific audits.
  • Maintain and track required licensure and registrations (city, state, DEA, HHS, and federal), coordinating renewals and compliance documentation as needed.
  • Assist in coordinating, compiling, and supporting UDS and PCMH reporting to ensure accuracy, completeness, and timely submission.
  • Provide oversight and coordination of HRSA BPHC Health Center Program compliance onsite visits, including pre-visit preparation, onsite support, and post-visit corrective action tracking.
  • Oversee and coordinate safety and facilities compliance activities to ensure adherence to applicable regulatory, accreditation, and organizational requirements, including X-ray and radiation monitoring, fire protection systems, generator testing, emergency preparedness planning, and required drills.
  • Coordinate and monitor healthcare compliance activities within programs such as Basecamp and oversee the management and compliance of Business Associate Agreements (BAAs) in accordance with HIPAA requirements.
  • Oversee electronic health record (EHR) access monitoring activities, including weekly review of eCW PSAC (Provider Self-Access Control) reports and authorization of provider self-access or access to family member records in accordance with privacy and security policies.
  • Provide oversight and coordination of legal, grants, and insurance compliance activities, including legal compliance requirements, grants, and HRSA form submissions, FTCA annual filing, and insurance renewals (E&O, property, liability).

  General Tasks

  • Ensure website content is accurate, up to date, and appropriate in accordance with organizational and regulatory requirements.
  • Punctual and regular attendance is required for this position.
  • Travel maybe required.
  • Working from home is not optional.
  • Perform other related duties as necessary for the purpose of ensuring the efficient and effective functioning of the organization.

• Bachelor’s degree in healthcare administration, public health, business, or a related field preferred; equivalent experience may be considered.
• Professional certifications such as CHC (Certified in Healthcare Compliance), CHPC (Certified Healthcare Privacy Compliance), CHRC (Certified in Healthcare Research Compliance), or HIPAA Privacy or Security Certification preferred.
• Minimum of 2 years’ experience in healthcare Compliance and/or QAQI required.

At least 5 years’ experience in healthcare Compliance and/or QAQI preferred