Career Opportunities
Job Title/Position: Director of Compliance and Education
Reports To: President/CEO
JOB DESCRIPTION SUMMARY
The Director of Compliance primarily job responsibility is to make sure that the
governing body adopts bylaws in accordance with the mission of the organization,
as well as making sure that mechanisms are in place to address the
recommendations made in the reports received from authorized regulatory and
accrediting bodies.
ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES
Put in place a comprehensive compliance program that includes:
1. The development and distribution of written standards of conduct, as well as
written policies and procedures, which promote the hospice’s commitment to
compliance.
2. Address specific areas of potential fraud, such as Medicare hospice
eligibility and admission, improper financial relationships with nursing
facilities and other healthcare professionals and entities, and improper billing
practices.
2. The designation of a corporate compliance committee, charged with the
responsibility for operating and monitoring the compliance program, and who
report directly to the CEO and the governing body;
3. The development and implementation of regular, effective education and
training programs in compliance for all affected employees;
4. The creation and maintenance of a process, such as a hotline or other
reporting system, to receive complaints and ensure effective lines of
communication between the compliance officer and all employees and the adoption
of procedures to protect the anonymity of complainants and to protect
whistleblowers from retaliation;
5. The use of audits and/or other evaluation techniques to monitor compliance,
identify problem areas and assist in the reduction of identified problem areas;
6. The development of appropriate disciplinary mechanisms to enforce standards
and the development of policies to address (i) employees who have violated
internal compliance policies, applicable statutes, regulations or federal
healthcare program requirements and(ii) the employment of sanctioned and other
specified individuals; and
7. The development of policies that direct prompt and proper responses to
detected offenses, including the initiation of appropriate corrective action and
preventive measures.
Practice Examples:
• Results of surveys are documented in governing body meeting minutes.
• Ongoing mock surveys or self-assessments are conducted to identify areas for
improvement and changes are made based on the findings.
• The hospice has a procedure for reporting and investigating compliance
concerns.