Compliance & Risk Manager

Job Description

Compliance & Risk Manager

Optimus Health Care is a Federally Qualified Health Care Center with sites operating in Bridgeport, Stamford and Stratford, CT. We are the largest provider of primary health care services in Fairfield County, proudly serving all patients regardless of their income, race, or insurance status. We are presently looking to add a full-time Compliance & Risk Manager.

The Compliance and Risk Manager (CRM) oversees and monitors with sufficient authority the Optimus Health Care, Inc., compliance activities, which are designed to guide the conduct of employees, as well as to maintain and foster the improvement of the quality of operational functions, clinical services, and products. Specifically, the CRM (a) manages Optimus’ Compliance Program; (b) promotes commitment to compliance with standards, policies, and procedures; (c) monitors adherence to the Compliance Program and facilitates the establishment of procedures to reduce identified problem areas and (d) promotes employee education regarding the commitment to compliance with all laws, regulations and guidelines applicable to the Optimus’ business. (e) The CRM will have direct oversite of the Medical Records department staff and service including subpoena management.

Essential Compliance Duties
Management
1.    Manages a process-oriented, company-wide Compliance Program that is guided by standards, policies and procedures, Code of Conduct, and HIPAA, and that effectively integrates subsidiary and key corporate departments (Reimbursement, Law, Human Resources, Education and Training, Internal Audit, Accounting) compliance program to ensure conformity with applicable laws and regulations.
2.    Works in conjunction with the internal business leaders and/or their designee as well as Human Resources, Finance, Clinical, Operations and Quality in establishing and maintaining all aspects of the corporate compliance programs.
3.    Supervises the activities and functions of the medical records personnel including monitoring of time off requests and payroll hours. 
4.    Appoints, coordinates, and directs the work of the staff members in the Compliance Department. 
5.    Directs the development and implementation of Compliance audit and review procedures, data
collection tools, and reporting processes that ensures the validity and reliability of corporate compliance programs. Coordinates with the Human Resources and the Finance department regarding compliance review and monitoring activities throughout the organization that may impact the compliance program.
6.    Oversees the confidential disclosure programs that effectively encourage managers,
employees, and others to report suspected improprieties without fear of retaliation. Maintains confidentiality regarding complaints to the maximum extent possible.
7.    Implements and maintains systems that ensure appropriate responses to compliance
complaints, disclosures, and reported problems in a timely fashion.
8.    Oversees internal investigations and actions on matters related to compliance, including the flexibility to design and coordinate internal investigations in response to compliance reports, audit results, reports of problems, or suspected violations and any resulting corrective actions. Ensures audits/investigations are promptly completed, corrective action is promptly taken, and disciplinary action is taken as appropriate.
9.    Consults outside counsel, after CEO and internal counsel review, at appropriate times to conduct specialized investigations to confirm or contest reported potential problems; protects the attorney-client privilege as appropriate.
10.    Oversees audits as mandated by government sources established to investigate and monitor compliance with standards and procedures implemented by the Compliance Program; reviews legal duties imposed by government agencies.
11.    Promptly responds to and cooperatively assists with external investigations following consultation with the CEO and internal counsel. Coordinates such activity with relevant management and personnel when appropriate.
12.    Assists and/or coordinates company-wide prevention and remedial plans and serving as
a resource in the development and implementation of departmental plans which facilitate compliance with quality standards following audits or investigations and ensures a reduction in identified problem areas and improved quality.
13.    Supports the medical records personnel with review of subpoenas and timely response to release of medical records ensure full compliance with required regulations including HIPAA.
14.    Maintains the company information security program in coordination with the Director of IT.
15.    Facilitates the education of management, staff, Board of Directors and contractors on compliance requirements, the Compliance Program, and all compliance-related activities; facilitates specialized training to ensure familiarity with relevant laws, regulation, standards, policies, procedures, and code of conduct. Establishes and maintains systems for effectively documenting such educational activity.
16.    Oversees vendor background screening functions when necessary.
17.    Maintains a central, confidential repository of compliance plans and reports for the purpose of study, analysis, and integration regarding issues, trends, and prevention/remediation plans; for developing education and training programs, and for senior management and board reports.
Administrative
18.    Plans, designs, implements, and updates the Compliance Program based upon the changing needs of Optimus Health Care, Inc., and changes in applicable laws and regulations.
19.    Coordinates various activities with the Human Resources to ensure appropriate use of government-sanctioned databases and appropriate implementation of staff member disciplinary and other corrective actions related to compliance issues.
20.    Keeps abreast of current changes that may affect health care systems through personal
initiative, Internet access, seminars, training programs, and peer contact.

Reporting
21.    Maintains a reporting system that provides timely and relevant information on all aspects of the Compliance Program.
22.    Periodically files formal reports to the CEO, Compliance Board Committee, and required outside sources on Compliance Program activities and findings and whether appropriate actions have been taken to address and correct any “out-of-compliance” situations.
23.    Establishes and maintains record keeping, tracking, and documentation retention
systems related to the Compliance Process that allow for appropriate analysis and reports.

Essential Risk Management Responsibilities 
Insurance Placement
1.    Negotiates with insurance brokers, insurance companies and third party administrators (TPA) with respect to premiums, terms and conditions of all property, casualty and liability insurance contract renewals, modification of existing contracts and placement of new insurance contracts as needed.
2.    Provides advice to senior management regarding insurance and risk management and keeps informed as to the Company’s insurance risks.
3.    Reviews and analyzes loss prevention reports from insurance companies and TPAs to remain informed about serious loss potentials and to ensure compliance with recommendations for minimizing and/or eliminating losses.
4.    Oversees the issuance issues certificates of insurance upon request and re-issues all certificates as policies renew or change.
5.    Reviews leases and contracts for insurance requirements, indemnity provisions and risk assessment. Recommends appropriate insurance values and deductibles for all physical damage, business interruption and liability insurance coverages.
6.    Administers all insurance policies  covering the organization, including adjusting,
approving and allocating premiums, verifying coverages, coordinating and reviewing audits and maintaining the policies.
7.    Maintains relationships with insurance brokers, insurers, and TPAs and serves as the
organization’s principal representative with brokers, carriers, and TPAs.
8.    In collaboration with the CEO, directs all insurance and risk management aspects of any acquisitions; incorporates merged and acquired companies in the Company’s insurance program.  
9.    Maintains records concerning fundamental decisions on treating risks, property valuations, retention of insurance policies, as well as correspondence affecting policies and other risk-related correspondence.
Risk Management
10.    Supervises the activities and functions of the compliance and risk management personnel. Appoints, coordinates, and directs the work of the staff members in the Risk Management department. 
11.    Develops and implements policies, procedures, guidelines, and processes for risk management functions to ensure compliance with applicable standards.
12.    Conducts periodic reviews of risk management staff case/work loads.
13.    Participates in various corporate committees as designated by the CEO/Board.
14.    Appraises all relevant department and business line managers of any risk management issues that may give rise to state or federal regulatory implications. 
15.    Recommends and contributes to associated policy and procedure development and revisions.
16.    Develops reports of loss control services and progress with initiatives for management and the Board of Directors.
17.    Ensure the FTCA Application for malpractice insurance is reviewed annually and all required additions and revisions to policies and procedures are developed and approved by the Board of Directors in an effort to address risk and minimize claims. 
18.    In collaboration with Quality, develops, coordinates, and administers risk identification, investigation, and reduction systems; maintains a network of information sources and experts for risk minimization and mitigation; performs risk surveys and data mining for root cause analysis and trends; develops loss control initiatives and educational opportunities; and works closely with selected clinical and non-clinical departments on compliance initiatives.
19.    Develops a comprehensive claims management process and supervises its administration. Oversight duties include receiving complaints and claims and working closely with claims risk managers, claims investigators in investigating and analyzing the claim while overseeing the negotiation and resolution of claims. 
20.    Oversees TPA claims handling processes, reserve setting and settlement authorities.
21.    Keeps business line management apprised of all necessary claims development and participates on risk management-related committees as appropriate.

Compliance Responsibilities
1.    Complies with applicable legal requirements, standards, policies and procedures including, but not limited to, those within the Compliance Process, Code of Conduct, Federal False Claims Act and HIPAA.
2.    Responsible for the implementation and maintenance of Optimus’ compliance program.
3.    Assist with the development and implementation of appropriate programs to assure that Optimus is compliant with applicable laws and regulations. 
4.    Ensure quality-assurance standards, licensing and policy implementation by monitoring and assessment of protocols and processes.
5.    Monitor productivity standards and audit results in order to ensure compliance with federal and state licensing requirements, including Joint Commission and HRSA.
6.    Oversee implementation of all Optimus policies and procedures to assure compliance with all state, federal and program requirements; this includes providing direction to policy and procedure owners in the development and revision of assigned policy manuals as well as policy distribution as required.
7.    Conduct confidential internal investigations for compliance complaints and or grievances, including those received via the Anonymous Hotline.  Creates a documented summary with recommendations for disciplinary and or corrective action, if necessary.  Works collaboratively with other department supervisors to ensure timely completion and follow-up as needed. 
8.    Ensuring the provision of appropriate orientation and training programs including, but not limited to, all required compliance courses and relevant policies and procedures, and that such training is properly documented. This includes the preparation and delivery of the mandatory regulatory compliance training.
9.    Work in conjunction with the Chief of Quality and Transformation and Chief Medical Officer to ensure compliance with Meaningful Use requirements.
10.    Participates in compliance and other required training programs.
11.    Perform miscellaneous duties as required by management.

1.    Strong knowledge base of healthcare regulatory environment and respective corporate compliance and risk management programs and processes.  Proven clinical proficiency and knowledge of quality improvement, compliance and risk management processes.
2.    Excellent communication and teaching skills required; teaching and training experience necessary.  Ability to communicate and interpret compliance policies, procedures, regulations, reports, etc. to personnel and government agencies/personnel.
3.    Ability to lead, plan, organize, develop, implement, and interpret the compliance and risk management programs, goals, objectives, policies and procedures, etc. that are necessary for supporting the delivery of quality care and maintaining sound business practices.
4.    Ability to apply critical thinking to a variety of situations, assess business objectives,
develop, implement and monitor effective business plans for improvement.
5.    Excellent computer skills required, specific experience with Microsoft Word, Excel, PowerPoint and data base management is recommended.

 JOB QUALIFICATIONS/REQUIREMENTS 

EDUCATION:  A Bachelor’s degree in business and legal administration; Master’s degree desired
EXPERIENCE:   Minimum of ten years of legal, clinical, and/or risk management experience; related work experience may be considered. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations, Research and investigation experience is highly desirable.

LANGUAGE SKILLS:  Bi-lingual Preferred but not required

MATHEMATICAL SKILLS: Advanced mathematical skills, including proficiency with Excel spreadsheets

REASONING ABILITY: Ability to apply critical, analytical thinking and problem solving skills to a variety of situations, assess business objectives, develop, implement and monitor effective business plans for improvement

LICENSURE / CERTIFICATION:  Maintain current corporate compliance certification for healthcare/HCCA

STANDARD REQUIREMENTS

    Supports an ethical standard, which complies with a code of conduct free of conflicts of interest.
    Supports the Mission and Values of Optimus Health Care, Inc. 
    Supports, cooperates with, and implements specific procedures and programs for: 
o    Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs. 
o    Confidentiality of all data, including patient, employee and operations data. 
o    Quality Assurance and compliance with all regulatory requirements. 
o    Compliance with current law and policy to provide a work environment free from sexual harassment and all illegal and discriminatory behavior. 
    Supports and participates in common teamwork: 
    Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgment. 
    Uses tactful, appropriate communications in sensitive and emotional situations. 
    Follows up as appropriate with supervisor and co-workers regarding reported complaints, problems and concerns. 
    Promotes positive public relations with patients, family members and guests.

Working for Optimus:
 • OHC provides a fun, fast-paced working environment, where our commitment to quality is present in every job function. 
• 100% Outpatient Setting
* Excellent health & welfare benefit options
• Competitive Compensation 
• Optimus and its caring, multi-lingual staff proudly serve our community in a patient-centered environment.
        
 We are proud to be an Equal Opportunity Employer