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Compliance and Accreditation Administrator

LCH Health and Community Services Kennett Square, PA

  • Expired: October 29, 2021. Applications are no longer accepted.

The Compliance and Accreditation Administrator’s primary responsibility is to ensure compliance at each of LCH's three facilities and offer support and training to each LCH service line. This position will work with LCH’s executive team to lead the organization to the highest quality and safety levels with measurable results.  Duties and ResponsibilitiesOversight and Administration of Healthcare Compliance Program:

  • Maintain Health Care Compliance Certification status. 
  • Maintain FTCA enrollment and deeming/redeeming applications accordingly.
  • Maintain a detailed documentation system that provides for an audit trail of all LCH compliance activities.
  • Facilitate trainings (OSHA, safety/risk management, infection control, etc.) and be the primary person responsible for ensuring regulatory compliance.
  • Ensure all health and safety procedures are followed and create a safety culture based on education/training and regulatory requirements.
  • Identify/incorporate best practices and lessons learned related to compliance into program plans.
  • Implement and oversee a compliance program, associated policies, and annual calendar in accordance with HRSA, FTCA, federal, state, and payor requirements. 
  • Ensure LCH’s success with operational-site visits by HRSA and other regulatory agencies and payors.
  • Participate as needed in special department projects.
  • Maintain PCMH accreditation through annual reporting process.
  • Work with the Director of Quality Care and Population Health to identify annual clinical quality measures, resource stewardship measures, and patient experience measures.
Oversight and Administration of Risk Management Program
  • Implementation of the risk management program, associated policies, and annual calendar.
  • Lead organizational incident reporting program including development of incident reporting forms, operational procedures, staff training, incident investigations, and remediation efforts. Ensure timely reporting of incident reports to Board of Directors Risk Management committee.
  • Annually, conduct internal assessment and/or oversight external audit of HIPAA Security Risk Assessment (SRA), coding and billing, 340B drug discount program, incident reports, and patient grievances.
  • Annually, conduct internal assessment and/or oversight of external high-risk areas audit as identified by HRSA and/or LCH.
  • Develop and continuously improve upon enterprise-wide risk assessment process for the purposes of identifying high-risk areas.
  • Oversee development of associated improvement activities resulting from risk management activities, including PCDA continuous quality improvement processes, operational procedures, and staff training.
  • Annually, create and ensure completion of risk management report to the Board of Directors.
Oversight and Administration of HIPAA Privacy & Security Program
  • Ensure organizational compliance with HIPAA privacy and security statutes, including training requirement for staff.
  • Act as LCH’s HIPAA privacy officer.
  • Develop and maintain organizational policies and operational procedures related to medical record confidentiality, record requests, privacy practices, and security measures.
  • Conduct annual Security Risk Assessment (SRA) and ensure appropriate follow-up activities to ensure security of LCH’s ePHI systems.
  • Develop annual auditing and monitoring schedule of ePHI systems and participate in IT security measures to ensure privacy and security of ePHI. 
Qualifications and Skills
  • Bachelor’s Degree required; 3-5 years’ experience working in a nonprofit environment is preferred.
  • Compliance and/or safety experience required.
  • Proven experience writing policies and procedures.
  • Analytical thinker with solution orientation.
  • Bilingual proficiency in English and Spanish is a plus but not required.
LCH is a culturally competent, bilingual, bicultural agency. Qualified members of the community are encouraged to apply.

LCH Health and Community Services


Kennett Square, PA
19348 USA



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