Remote Fraud Risk Management Jobs in Lehigh Acres, FL

Job Summary:    The Compliance Officer is responsible for the overall direction and oversight of the organizations compliance & ethics plans/programs, and oversees the Avow compliance professionals for all Avow clinical companies.  The Compliance Officer is responsible for the overall direction and oversight of compliance, quality initiatives, performance improvement, policies and procedures, education, and infection control.

This position, reports dotted line to the CEO and Board Chair to identify and mitigate organizational high risk issues or incidents. The position reports directly to the Chief Operating Officer.

Responsible for providing vision and leadership in creating a best-practice environment and in conjunction with executive clinical operations leaders a superior, compliant patient care delivery system through quality management. Manages multiple projects and demands with shifting priorities, initiative, decision making skills, independent judgments and critical thinking skills, group facilitation skills to promote multidisciplinary collaboration and lead groups, resolve conflict, remain flexible and facilitate teamwork.

Job Responsibilities: 

Compliance Officer    

• Implements, oversees and manages the corporate compliance program including a direct reporting relationship on compliance matters to the CEO and the Board Chair.
•  Provides for investigations into any identified high risk areas or reported potential breaches and recommends to the CEO and Board Chair and involved executive leaders, any corrections or changes leading to mitigation of those risks. Assists leaders and monitors the risk mitigation process to ensure it is implemented.
• Keeps current with and communicates relevant information from the Office of the Inspector General (OIG), Florida Agency for Healthcare Administration (AHCA) regulations, fraud alerts and advisory opinions. Plans and manages Avow’s compliance and audit programs in accordance with directives and priorities of these governing bodies.

• Encourages all employees and volunteers to report any suspected compliance or ethical breaches for investigation without fear of retaliation. Investigates all reports and presents findings to appropriate parties. Utilizes external resources such as regulatory attorneys and compliance consultants to assist with guidance related to follow up on reported issues.
• Reads, analyzes, summarizes, reports and recommends to organizational leaders any proposed and new federal and state regulations and regulatory standards and other pertinent specialty accreditation requirements to provide direction for the company response.
• Reviews compliance activities and oversees the quality management activities, in collaboration with the clinical operations leaders, in developing action plans for areas identified as non-compliant.
• Recommends to the Executive Leadership Team methods to improve efficiency and quality of services to reduce vulnerability to fraud, abuse and waste. 
• Serves as key contact person to directors responsible for compliance and assigned standards and other regulatory requirements.
• Conducts on a regular basis the Enterprise Risk Management process with the Executive Leadership Team and reports results to the Board annually.
• Designs and implements an annual Audit plan for the organization in conjunction with the operations leaders to focus on areas of concern or priority elicited from previous audits, compliance concern reports/investigations, OIG Workplan, ERM Tools, staff education and documentation learning need trends, new regulations and high risk areas.
• Sits on the Board Quality and Compliance Committees and reports regularly to them; the organization’s trends and outcomes. Ensures recommendations by the Board Quality and Compliance committees are implemented and reported on for follow up.

Quality Assurance and Performance Improvement     

• Oversees and monitors the implementation of the quality assessment & performance improvement programs and processes
• Leads the development and implementation of all clinical policies, procedures and protocols and ensures alignment with regulations, ERM system integration and organizational objectives. 
• Works with all disciplines from front line staff to executive leaders to impart an understanding of regulatory and compliance requirements and prepares staff across the organization to imbed regulatory requirements into daily operations through mock tracers, survey readiness rounds, training and regulatory audits.
• Leads the organization’s survey processes including survey readiness and assists with the activities of on-site and remote auditors, surveyors and consultants to ensure they receive requested information and follow up
• Ensures the QAPI processes and program are fully implemented, monitored and lead to quality and performance improvement across the organization.
• Manages organizational Performance Improvement and Sentinel Event investigations, follow up and reporting internally and externally as needed
• Oversees the Joint Commission IntraCycle Monitoring (ICM) Process and Conditions of Participation Review.
• Assists in the organization’s effort, in collaboration with IT, to create protected and compliant electronic health information records.
• Maintains corporate quality, compliance and regulatory files including regulatory requirements, survey and audit reports, OIG, CMS and other government and JC directives.
• Manages the organization’s QAPI Committee. Sits on the Board Quality and Compliance Committees and reports regularly to them, the organization’s status and outcomes. Ensures recommendations by the Board Quality and Compliance committees are implemented and reported on for follow up.

Clinical Documentation

• Provides for initial and ongoing education of clinical staff on EMR to support and maximize utilization, compliance and efficiencies.
• Develops and oversees the organization’s written Audit plan to identify and address learning needs, improve performance and maintain compliance. Reports trends, high risk areas and action plans and adjusts the audit plan on an ongoing basis as needed.
• Maintains updated knowledge in health information record management, documentation requirements for all clinical disciplines and external collaborative practitioners such as referring physicians, long term care facilities, hospitals, etc.
• Fosters collaboration with IT department and external parties’ electronic records systems to enable integration, improve information sharing and maintain patient information privacy standards
• Provides expert clinical resource in health information coding to maximize compliance with documentation requirements and billing capacity and compliance with third party payers.
• Provides for collaboration with Billing, Service Integrity and IT departments and documentation consultants to ensure best practices related to clinical documentation are being implemented.
• Ensures all governmental and payer clinical documentation required reporting is planned and executed per payer guidelines and deadlines.

Customer Service and Feedback Response System         

• In collaboration with the executive team, ensures compliance with CAHPS satisfaction survey, tracking, reporting processes to comply with government reporting requirements and to assist the organization in achieving its satisfaction rating goals in accordance with the annual strategic plans.

Education            

• Develops an annual Education Plan with Service Integrity and Operations leaders that addresses high risk areas, identified learning needs and growth opportunities for clinical staff.  Coordinates learning opportunities among all clinical departments to ensure consistent messaging and targeted education goals are met.
• Plans and administers the creation and provision of regular targeted staff educational programs to educate staff to help them maintain best practices, compliance with current clinical regulatory requirements and to improve their professional development.
• Works with leadership and operations leaders to coordinate education and support to staff as needed.
• Oversees the management of the organization’s Education Committee working with clinical operations and support leaders and staff to identify learning needs and address them in a timely manner by providing high quality education programs.
• Provides for the management of schedules and contractually arranges with area universities and colleges for interdisciplinary clinical rotations for students and interns on an ongoing basis. Ensures the coordinates staff joint visit schedules with clinical operations leaders.
• Provides for the maintenance of all mandated clinical staff education tracking, evaluation and needs identification processes as required by regulation.
• Provides for the management of the organization’s CE program.
• Responsible for the management of the organization’s general orientation processes.

Executive Leadership

• Develops budgets and plans for areas of responsibility and monitors and reports on achievement of departmental goals on a regular basis to CCO and Executive Leadership Team as appropriate.

• As a leader on the Leadership Team, provides guidance to the team and the Board on policy and practice that continuously improves the quality of service and support provided to patients, family and community.
• Collaborates with operational and financial leaders to ensure full integration of quality and compliance processes within the organization and that those processes are improving efficiencies and quality of care and service.
• Surveys peers, the Board of Directors and staff/volunteers regularly to gain feedback on the compliance program’s impact on the organization and gather feedback to integrate into future compliance activities.
• Maintains current knowledge and expertise in areas of responsibility through educational and networking. Serves as the lead Compliance, Quality, and Education expert on the Executive Leadership Team.
• Assists the Executive Leadership Team to develop organizational strategic plans, financial plans, enterprise risk assessments and mitigation plans and guides the team to determine the areas needing improvement or changes to become more compliant, productive or to improve overall quality of care and services.
• Reports directly to the CEO and the Board Chair any high risk compliance issues that require further investigation and follow up at the highest organizational levels. Assists the organization’s leaders to resolve compliance issues in a timely manner to avoid any incidence of potential fraud, abuse, waste or neglect.
• Ensures that the organization’s Compliance and Ethics Program/Plan is updated regularly as needed, provides for training for Board, volunteers and staff on the program and that the program is always in accordance with current law, regulations and best practices.
• Other duties as assigned

Supervisory Responsibilities:  Manages subordinate managers, directors and support staff in Service Integrity unit including areas of Compliance, Quality,  Education, Informatics, Infection Control & Employee Health, medical records and any other assigned departments.  Responsible for the overall direction, coordination, and evaluation of these units.  Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Education/Experience: Masters Prepared Registered Nurse preferred, with experience in Health Care Compliance & QAPI Standards. Experience in health care management, hospice experience and working knowledge of Joint Commission and or CHAP guidelines, survey readiness and ERM systems is preferred. Public speaking and/or training experience preferred.

Certificates, Licenses, Registrations:

CHC certifications preferred and required within 12 months. Valid Florida driver’s license.

Language Skills:

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.  Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.  Ability to write speeches and articles for publication that conform to prescribed style and format.  Ability to effectively present information to top management, public groups, and/or boards of directors.

To perform this job successfully, an individual must demonstrate competency in each of Avow’s core values listed below and be able to perform each essential duty satisfactorily.  The requirements listed are representative of the knowledge, skill, and ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Core Values:

Innovation:

We embrace change and are always looking at creative ways to solve problems and serve new populations.

Integrity:

We are honest, hardworking, fiscally responsible professionals driven solely by the well being of our patients, their loved ones, and the communities we serve.

Collaboration:

We know we cannot achieve everything we want without working hand-in-hand with each other, with our healthcare partners, and with the community.

Celebration:

We believe in the importance of celebrating life and relationships.

Education:

We believe it is important not only to serve the community but to educate community members about our services and the role we can play at the end of life.

All applicants offered a position are required to complete a screening through the Clearinghouse.  For more information, click here https://info.flclearinghouse.com.