Director of Compliance

Position Summary:

Reporting to the Chief Operating Officer this position is responsible for developing and coordinating compliance programs that monitor operational and programmatic compliance. This position for the development of clinical standards and training programs.

Primary Responsibilities:

1. Direct the development implementation and evaluation of department goals objectives policies procedures and standards of practice; with contribute to the delivery of care.
   1. Define implement and maintain program and operational indicators that support

monitor of program compliance.

1. 1. Develop and implement tools to conduct effective program evaluation.
   2. Establish accreditation/regulatory preparation process and implement to ensure all

areas achieve successful accreditation.

1. 1. Perform and coordinate performance audits to identify areas of concern and ensure

uniformity of practice standards.

1. 1. Collaborate and coordinate with the Director of QI/Compliance to ensure regulatory

standards are met and maintained.

1. To coordinate develop and present educational/training programs to maintain enhance and assess job performance and competencies of staff.
   1. Develop and implement a training curriculum programs and training programs materials that promotes educational events and presents programs based on employee and management request and needs assessments.
   2. Conduct and arrange for educational training sessions.
   3. Conduct competency testing by collaborating with staff and management to determined competencies and the method of assessing those competencies through skill demonstration and or written assessment.
   4. Provide review of job description and competencies in conjunction with Human Resources for nursing and other designated clinical staff.

1. 1. Provide feedback regarding staff skills reassessing specific needs creating action plans and conducting or making provision for the affiliated health care agencies.
   2. Assist Chief of Staff as meeting planner with external visiting groups.

1. Direct activities related to the development and maintenance of administrative and clinical policies and procedures.

1. 1. Perform annual review and update of policies and procedures.
   2. Serve as clinical liaison on various internal and external committees involved in

establishing policies and procedures.

1. 1. Coordinate with the clinical leadership in the development of new procedures.
   2. Act as a resource to the community outreach programs and other health-care organizations.
   3. Supervise and manage special project activities.

Qualifications and Skills:

• BSN an allied health field or management.
• Experience with staff and program development.
• Knowledge of accreditation standards federal guidelines and health care organizational standards.
• Strong written and verbal communication skills.