Associate Director of Risk Management, Compliance, and Training

POSITION TITLE:                  Associate Director of Risk Management, Compliance, and Training

DEPARTMENT:                     Administration

REPORTS TO:                       Legal Officer

SITE/HOURS:                        40 hours per week, Monday – Friday. Travel to other nearby sites is required.

Salary Range: $105,580.80 To 117,113.00 Annually

Since 1972, OLE Health has provided comprehensive care to all individuals regardless of insurance or ability to pay. OLE’s Health offers primary care, dental, optometry, and behavioral health services and embraces a patient-centered model of care. By emphasizing care coordination across departments, as well as referral and enrollment services, we ensure all the patients’ health and well-being needs are met. OLE Health has six health centers across Napa and Solano County and serves 40,000 patients annually.

 

JOB SUMMARY: The Associate Director of Risk Management, Compliance and Training manages the oversight and maintenance of a high-quality, effective, risk management, compliance, and training program, with the purpose of preserving best-practices, and preventing, detecting, and addressing violations of law, misconduct, or other activities that threaten our culture of ethical, transparency and accountability. The Associate Director of Risk Management, Compliance and Training is responsible for the development and implementation of the Risk Management, Compliance, and Training Program, including the development, implementation, and evaluation of the program governance and structure, policies and procedures, standards of conduct and culture, relevant staff training content, internal monitoring and audits, and reporting. The incumbent will work with the Chief Operating Officer, Legal Officer, and other organizational leaders to develop, design, implement, evaluate and manage a comprehensive training program for the organization. The Associate Director of Risk Management, Compliance, and Training ensures compliance with federal, state, and local laws and regulations, investigations, accreditor standards, and institutional policies and procedures. Our organization is a federally qualified health center providing comprehensive patient-centered primary care services including medical, dental, substance use treatment, mental health, health education and outreach services to low income, multi-ethnic, uninsured and underinsured populations.

Expectations:  Self-starter who can work independently with little or no supervision. Ability to work well with multidisciplinary team, to problem solve and handle complex issues with minimum supervision. Ability to assimilate new information and communicate effectively to others is critical.  Must have a commitment to excellence and high standards. Must have commitment and ability to serve and deal effectively with a diversity of individuals at all organizational levels and with external customers. Must have ability to manage priorities and workflow. Required to have versatility, flexibility and a willingness to work within constantly changing priorities with enthusiasm. Must possess strong interpersonal skills and have the ability to understand and follow written/verbal instructions.

DUTIES AND RESPONSIBILITIES

 

Develop and implement a Risk Management and Compliance Program. Identify and analyze risk management and compliance program requirements; draft key documents such as Corporate Compliance Plan and Risk Management Plan, and implement through coordination with the organization’s department infrastructure.

  • o   Promotes consistent, ethical practices and maintains a commitment to safety, risk mitigation and compliance through knowledge and application of relevant federal, state, and local laws, rules, regulations and internal policies and procedures.
  • o   Maintains current understanding of, and anticipates impact of, industry standards, trends and emerging needs.
Governance and structure: create and implement formal organization and governance that establish clear roles and accountability for risk mitigation and regulatory compliance.

  1. Develop and manage effective lines of communication for reporting instances of potential non-compliance, including, and not limited to Incident Reports. Ensure communication for reporting is accessible, confidential, clearly conveys our organization’s compliance standards, encourages feedback, and provides methods for anonymous reporting.
    • Staff the Risk Management and Compliance Committee of the Board.
  1. Serve as Project Lead for HRSA Operational Site Visits..
  2. Serve as the Civil Rights Coordinator for the organization.
Policy and Procedure:

  • o   Oversee ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures.
  • Identify the need for both new policy and procedures and revision to existing policy and procedures that promote our organization’s commitment to compliance and address specific areas of risk. Routinely write, review, and update our organization’s policies and procedures.
  • Oversee all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering Section 1557 of the Affordable Care Act of 2010.
Standards of Conduct and Culture:

  1. Work with Human Resources Department to ensure standards of employee conduct outline our organization’s rules, responsibilities, proper practices, and expectations. Promote and reinforce standards of conduct and a culture of compliance (regardless of position, title, or rank), as a result of ongoing, proactive program development and oversight
  2. Embed controls that promote any individual’s potential to find and correct potential vulnerabilities, reduce the chance of fraud and abuse, and promote safe and quality care.
  3. Support our organization’s employees to perform their job functions in a manner that ensures compliance with Federal healthcare program requirements.
  4. Support implementation of process and infrastructure development to ensure employee participation in risk mitigation and compliance programming.
Support content development for staff training:

  1. Fraud, abuse, healthcare regulatory compliance, confidentiality, privacy, security, and the organization’s Compliance Program;
  2. Maintaining a safe work environment, and compliance with the rules of the Illness and Injury Prevention Program.
Internal Monitoring and Auditing:

  1. Develop, and maintain a risk management plan. Establish and implement on-going risk assessment and compliance work plan, proactively identifying areas of risk and targeted mitigation strategies. Audit performance and implement proactive solutions to reduce risk and improve compliance.
  2. Provide ongoing evaluation and assessment to ensure effectiveness of risk management and compliance programming and effectiveness of employee education and corrective action as it directly pertains to risk management and compliance. Problem solve and oversee resolution to known gaps in implementation of risk and compliance program implementation.
  3. Continuously monitor and analyze data related to program outcomes and consumer satisfaction to identify opportunities for improvement. Assess patient satisfaction, achievement of project objectives, and include a process for hearing and resolving patient grievances. Ensure Patient Satisfaction Survey reports are created and presented to the QI Committee on a quarterly basis.
  4. o   Analyze and assess compliance with Federally Qualified Health Center, federal state and county regulations and licensure.
  5. o   Support the Quality Assurance Program. Evaluate quality management processes, program outcomes, and administrative efficiencies by identifying and assigning priority to opportunities for performance improvement.
Reporting:

  • o   Oversee compliance to meet the requirements of the Federal tort Claims Act (FTCA) and submit to our organization’s annual FTCA application.
  • Report on the status of risk management activities and progress in meeting risk management goals.
In collaboration with our leadership, compliance, clinical services, and quality improvement, assess and identify training and development needs, interventions, and resources.
Perform needs assessments using a variety of resources, such as employee feedback, performance data, and testing tools to identify gaps in training, skills and performance.
Assess and maximize use of on-line training services, including Relias Learning. Develop on boarding programs and position-level training plans for employees/groups of employees in collaboration with leaders and managers.
Work with established programs to ensure that all employees receive training required for their position.
Develop training programs and/or update existing programs and develop and maintain training materials, as needed.
Identify and collaborate with training providers/vendors as needed.
Conduct training and/or arrange for guest lecturers/trainers to cover technical issues, new products/services, individual on-the-job training, or other training as necessary.
Maintain training schedules and records and oversee scheduling employees for ongoing training sessions.
Assess effectiveness of trainings and make recommendations for improvements.
Measure learning transfer of training programs to enhance individual and team effectiveness.
Produce periodic reports including outlining training needs and recommendations.
Monitor, evaluate and make recommendations regarding cost effectiveness and quality of learning programs.
Assess and maximize the use of on-line training services, including Relias Learning. Develop onboarding programs and position-level training plans for employees/groups of employees in collaboration with leaders and managers.
Work with established programs to ensure that all employees receiving the required training for their position.
Regular travel to all agency sites required
Other special projects as assigned.

EDUCATION, EXPERIENCE, TRAINING

  1.       Bachelor’s degree (a Master’s degree in Public Health or other advanced health or social services degree is preferred)
  2.       Two years or more of work experience coordinating and managing risk management, compliant, and training activities and/or volunteers
  3.       experience working in a health care organization highly desired
  4.       Demonstrated experience with project management required
  5.       Experience working with curriculum development and instructional design preferred. Demonstrated ability in quantitative and qualitative analysis
  6.       Strong interpersonal skills required
  7.       Intermediate to advanced proficiency using Microsoft Office applications (Excel, Word, PowerPoint) required
  8.       experience using training/tracking computer-based programs strongly preferred
  9.       Must be well organized and have a high level of attention to detail and accuracy. Must possess exceptional verbal and written communication and presentation skills
BENEFITS:

 10 Paid Holidays

 Vacation & Sick (16 days)

 Medical, Dental, Vision

 403(b) retirement plan with a 4% match

 Tuition Reimbursement

 Life insurance

 Flexible Spending Account

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