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Chief Administrative Officer/General Counsel


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

Job Summary

The CAO serves as General Counsel and the Risk and Compliance Officer for the Health Center. Regarding compliance related matters, the CAO also reports to the Quality Assurance Board Chair (or designee). This position has the principal authority and responsibility for the development, implementation, oversight and evaluation of a dynamic integrated enterprise risk management and compliance program organization wide. This position reports to the Chief Executive Officer and will advise the CEO on legal strategies to enhance the work of the community health center.

Duties and Responsibilities

  • Serves as health center counsel advising the CEO on legal strategy and coordinates work with external attorneys when necessary.
  • Coordinates with CEO or his/her delegate on composition and delivery of responses to state regulatory agency complaints and inquiries.
  • Stays current on all HRSA 330 Federal Grant requirements, notifies leadership of important updates, and prepares for HRSA On-Site Visits.
  • Assists in the completion of applications to state agencies such as Kentucky Department of Public Health, the Department of Health Care Services, and the Board of Pharmacy.
  • Drafts, reviews and updates all health center contracts, MOU's, and agreements.
  • Ensures all agreements are archived and logged into our contract management system.
  • Ensures any contracts for goods or services follow HRSA 330 Grant requirements.
  • Drafts formal correspondence to opposing parties in the event of a contract dispute.
  • Oversees the development, management and annual review of SHS's policies and procedures, in collaboration with policy owners and executive reviewers.
  • Oversight of Medical Records, Risk and Compliance Coordinator, Facility and Grounds staff
  • Develop an enterprise risk and compliance strategy including objectives, identification of key risks, and controls that are aligned with policies, procedures and operating principles.
  • Develop and implement a corporate infrastructure that facilitates early identification of new risks, incident identification, communication, issues management and internal and external reporting.
  • Annually assign/conduct a Compliance training to all front line staff. Cultivate relationships with front line staff to foster a culture of safety and be available to consult with front line staff on compliance related issues.
  • Advises front line staff on patient consent issues, minor consent issues, mandated reporting, and any other patient issues that may arise.
  • Supports the Chief Medical Officer in the clinical risk management processes to ensure a culture of safety, timely capture of events, reporting to insurance and federal agencies and initiation of risk analysis for all events.
  • Supports the HR Manager with the management of the Workers' Compensation Insurance coverage to include Workplace Safety Risk Controls and Claims Management.
  • Oversee and monitor the development and implementation of the Corporate Compliance Plan, Manual and Work Plan
  • Establish methods such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing written practice standards and procedures to improve the health center's efficiency and quality of services and to reduce health center's vulnerability to fraud and abuse as outlined by the Office of the Inspector General.
  • Chair the Corporate Compliance and Risk Management Committee
  • Periodically revise the Compliance Plan, by recommending such revisions to the Corporate Compliance and Risk Management Committee, in light of changes in the needs of health center or changes in the law and/or in the standards and procedures of government and private payer health plans
  • Advise on matters related to HIPAA regulations and required controls including periodic Risk Assessments and Medical Records Release of Information.
  • Ensure that independent contractors, consultants and volunteers who furnish medical services to health center are aware of the requirements of the Corporate Compliance Plan
  • In conjunction with the HR Manager, insure that the HHS OIG's List of Excluded Individuals and Entities, and the General Services Administration's (GSA's) List of Parties Debarred from Federal Programs have been checked with respect to all employees, medical staff and independent contractors
  • Monitor the Compliance Hotline; Investigate and resolve any reported issues.
  • Independently investigating and acting on any report or allegation of unethical or improper conduct or business practices, reporting on the results of such investigations to the Corporate Compliance and Risk Management Committee, and implementing and monitoring appropriate corrective action and/or subsequent compliance
  • Reporting on a regular basis to the Board of Directors and CEO on the progress of the Compliance Plan's implementation and on the methods adopted to improve the health center's efficiency and quality of services and to reduce its vulnerability to fraud and abuse.
  • Responsible for the management and processing of FTCA claims and serves as the claims point of contact any such claims.
  • Responsible for the review and management of all potential or actual claims such as employment, workers compensation, medical malpractice, and professional board complaints.
  • Supports the medical records department by reviewing subpoenas and helping staff determine how to answer the subpoena.
  • Continuing the momentum of the Corporate Compliance Plan and the accomplishment of its objectives after its implementation.
  • Participates on the Quality Improvement Committee, the Retirement Committee, and the Leadership Group.
  • Other duties as assigned


  • Bachelor's degree in related field and a minimum of 3 years of recent experience in health care corporate compliance and risk management at a manager level or above.
  • Juris Doctor Degree and successfully passed the Kentucky Bar Exam
  • Three years of legal or health care experience is highly recommended.
  • Knowledge of healthcare issues in FQHC's
  • Knowledge of State and Federal healthcare regulations including HRSA 330 Grant Requirements, HIPAA and other relevant security/privacy laws, and CMS Conditions of Participation.
  • Excellent written and verbal communication skills
  • Valid KY Driver's License, proof of insurance and personal transportation.


  • Highly effective collaboration skills, written and verbal communications skills.
  • Computer competent and able to present key information in a succinct and clear manner.
  • Ability to facilitate conflict resolution, competent in identification of risk situations and resolution.
  • Ability to communicate well with families, patients, staff and physicians based on age, cultural beliefs and educational level.
  • Attention to detail, meticulous development and maintenance of regulatory paperwork.
  • Speaks with confidence and command.
  • Knowledge of organizational policies, procedures and systems
  • Ability to interact with internal personnel and external agencies requiring reasonable tact, discretion, and self-expression.
  • Ability to maintain open dialogue with supervisors and management staff.
  • Ability to work independently, use good judgment, maintain excellent communication skills and self-initiative.
  • Ability to establish and maintain effective working relationships with employees and the public

Special Requirements

Requires sitting, standing and walking for extensive periods of time. Requires working under stressful conditions or working irregular hours. Requires frequent exposure to communicable diseases, body fluids, toxic substances, medicinal preparations and other conditions common to a clinic environment. The employee frequently is required to reach with hands and arms. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to work with a moderate noise level in the work environment is required.

The above information is intended to describe the most important aspects of the job. It is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required in order to perform the work. The health center reserves the right to revise or change job duties and responsibilities as the business need arises. Additionally, this job description is not intended as an employment contract, implied or otherwise, and the Center continues to maintain its status as an at-will employer.

If the essential functions of this position cannot be performed in a satisfactory manner by the employee, reasonable accommodations may be made.



Mount Sterling, KY