Compliance Officer

About the Organization

The mission of Specialized Treatment Facility (STF) is to promote and strengthen the mental health and education of up to 48 adolescent males and females who are experiencing behavioral difficulties in their homes, schools, and communities. Employees are charged with furthering STF's mission by exhibiting the core values that are at its heart: Teamwork, Respect, Compassion, Integrity, and Safety. STF employs milieu therapy as the foundation for the treatment of its residents. Milieu therapy is a planned treatment environment in which everyday events and interactions are therapeutically designed for the purpose of enhancing social skills and building confidence. This therapy uses common structures familiar to all children, such as daily routines, consistent rules, and activities.

About the Role

The Compliance Officer is responsible for ensuring that the program is in compliance with all applicable laws, regulations, and standards. This role requires a thorough understanding of these laws, regulations, and standards, including staying up to date on changes and communicating those changes within the organization. The Compliance Officer will develop, monitor, and disseminate policies and procedures, report to management on compliance issues, and identify potential areas of compliance vulnerability and risk. The Compliance Officer will report directly to the Program Director and will supervise the Performance Improvement Coordinator, Quality Assurance Investigator/Risk Manager, Peer Support Specialist, and Resident Advocate.

Responsibilities

• Monitors and manages compliance with applicable PRTF and healthcare regulations, including CMS requirements, MS State Department of Health Minimum Standards, Division of Medicaid's Administrative Code, Joint Commission, Department of Mental Health, Health Insurance Portability and Accountability Act (HIPAA), Disability Rights Mississippi, and STF's policies and procedures.
• Analyzes new and revised laws and regulations to determine the need for changes in policies, procedures, systems, forms, and publications; stays abreast of developments in laws, ethics, audit requirements, and documentation.
• Manages, monitors, investigates, and responds to safety incidents, HIPAA concerns, and other compliance issues.
• Collaborates with other managers to maintain and revise policies and procedures to ensure proper enforcement and adherence; advises management on needed actions.
• Develops and maintains the program's Employee Operations Plan and other safety/risk plans as required by regulating bodies.
• Facilitates training programs for new employees and ongoing training for existing staff on compliance issues, policies, procedures, and related matters.
• Prepares reports for internal and external use related to STF's compliance program, including developing and implementing an effective system for collecting and disseminating data and information.
• Leads preparation for regulatory site visits, including managing the collection and review of necessary documentation, acting as liaison during these visits, and facilitating the program's response to site visit findings.
• Participates in various committees, including but not limited to program leadership, Performance Improvement (PI), Environment of Care (EOC), and Human Rights Advocacy Committee (HRAC).
• May assist Human Resources with credentialing of professional staff.
• Supports resident and staff complaint and grievance processes.
• Works closely with other departments to ensure STF's compliance with all applicable laws and standards.
• Serves as the program's HIPAA Privacy Officer and Compliance Officer.
• Supervises and directs subordinate staff, including assigning and reviewing work, hiring new staff, and evaluating work performance.
• Adheres to MS State, MS DMH, Joint Commission, DOM, MSDH, and STF policies and procedures and participates in continuous learning.
• Maintains a valid driver's license and liability insurance to be a driver of a state vehicle.
• Maintains Mandt certification as required by STF.
• All STF employees are responsible for reading, understanding, and adhering to all policies, protocols, and memorandums. Universal precautions and infection control policies must be adhered to by all STF employees.

Requirements

Requires a Bachelor's Degree in Healthcare Administration, Business, or another field related to position responsibilities. Experience in the healthcare field may be substituted for the education requirement.

Physical Requirements

These physical requirements are not exhaustive, and additional job-related physical requirements may be added by STF as needed. Corrective devices may be used to meet physical requirements. Reasonable accommodations may be possible.

• Heavy Work: May frequently exert force equivalent to lifting up to approximately 50 pounds and/or occasionally exert force equivalent to lifting up to approximately 100 pounds.
• Vision: Requires the ability to perceive the nature of objects by the eye.
• Near Acuity: Clarity of vision at 20 inches or less.
• Midrange: Clarity of vision at distances of more than 20 inches and less than 20 feet.
• Far Acuity: Clarity of vision at 20 feet or more.
• Depth Perception: Ability to judge distance and space relationships to see objects where and as they actually are.
• Field of Vision: Ability to observe an area up or down, left or right while eyes are fixed on a given point.
• Accommodation: Ability to adjust focus.
• Color Vision: Ability to identify colors.
• Speaking/Hearing: Ability to give and receive information through speaking and listening skills.
• Smell: Ability to use the sense of smell to recognize and distinguish odors.
• Motor Coordination: While performing the duties of this job, the incumbent is regularly required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; stoop, kneel, crouch, or bend. The incumbent is occasionally required to sit and climb or balance.

Skills

• Knowledge of general office practices and administrative procedures.
• Knowledge of behavioral and mental health procedures.
• Knowledge of HIPAA, Joint Commission, CMS, and other healthcare-related regulating bodies.
• Proficient knowledge and skills in computer use.