**Job Summary:**Under the direction of the EMMC Vice President of Compliance andPrivacy, the Compliance Officer - Regulatory/Licensure (CORL) willimplement and oversee the EMMC Compliance Program related to theMedicare Conditions of Participation, State Licensure and The JointCommission (TJC) Standards. The CORL will be responsible forimplementing policies, procedures and practices designed to ensure EMMCcompliance with Medicare Conditions of Participation. The CORL will bethe primary contact person for all external surveys related to licensureand accreditation. The CORL will provide assistance and guidance to, andshare relevant information and recent developments with, all Memberhospitals related to the Medicare Conditions of Participation, Licensureand The Joint Commission (TJC) Standards. The CORL position also hasmatrix reporting to the Northern Light Health Director of Compliance andPrivacy. The CORL must possess personal computer proficiency, acommitment to high quality customer service and the ability to managemultiple projects and priorities. The CORL must have the highest degreeof integrity, professionalism, and possess interpersonal skillsnecessary to develop and foster effective relationships with all levelsof management at the various Northern Light Members.**Education and Experience:**? Bachelor's degree required. Graduate degree in Law, Business, HealthAdministration or suitable related discipline preferred.? Experience with CMS Conditions of Participation required.? Experience with accreditation surveys required.? Experience with plans of correction in response to statements ofdeficiencies required.? Experience interpreting and implementing TJC Standards, Conditions ofParticipation, State Licensure Regulations, and Medicare and Medicaidprogram requirements strongly preferred.? Minimum of 5 years health care operational experience required.Direct clinical experience preferred. Health care leadership experiencepreferred.? Minimum of 2 years experience with health care-related regulatory andcompliance issues required.? Experience in hospital operations preferred. Acute care hospitalcompliance officer experience preferred.? Familiarity with health care laws, regulations, and standards,including HIPAA preferred.? CHC/CHP/CCEP preferred.**Required Minimum Knowledge, Skills and Abilities:**? Must clearly demonstrate the ability to partner effectively withothers to resolve complex regulatory issues.? Must have familiarity with general regulatory compliance environmentand requirements of healthcare organizations.? Certified in Health Care Compliance (\"CHC\") preferred, otherwise mustobtain certification within one year of hire.? Certified Joint Commission Professional CJCP preferred, otherwise mustobtain certification within 3 years of hire.? Excellent communication skills, both verbal and written.? Strong analytical skills.? Attention to every detail.? Highest degree of credibility, integrity and discretion.? Comfortable working independently and able to effectively managelarge, complex projects through their entire life cycle with minimalsupervision.? Thrives on wide variety of intellectually challenging work.? Comfortable assessing complex facts that may not lead to a black orwhite answer.**ESSENTIAL FUNCTIONS:**? Oversee EMMC's program designed to maintain compliance with JointCommission/Medicare Conditions of Participation standards.? Serve as EMMC's primary liaison with surveyors including JointCommission and State Licensure.? Develop, initiate, maintain and revise EMMC policies and proceduresrelevant to areas of responsibility.? Oversee EMMC compliance with State Licensure regulations.? Provide compliance support for other areas of the EMMC complianceprogram.? Advise, educate and direct EMMC employees and medical staff onregulatory issues within areas of responsibility.? Provide ad hoc guidance via phone, email and in person.? Respond to EMMC Compliance Hotline patient safety concerns.? Conduct auditing and monitoring of patient care services and thephysical environment at all EMMC locations.? Work collaboratively with other EMMC departments in developingrequired responses to State, Federal and The Joint Commission identifiedareas of non-compliance and track progress of corrective actions.? Work collaboratively with EMMC Patient Experience to respond to TJCOffice of Quality and Patient Safety events.? Make required notifications and application updates to State and TJCon behalf of EMMC.? Facilitate risk assessments as needed to identify potential areas ofvulnerability and risk at all EMMC locations.? Lead EMMC hospital-wide tracer activities.? Chair EMMC TJC Compliance Committee? Serve as active member of EMMC's Hospital Quality Committee, all TJCChapter Committees and other Patient Safety Committees and EMMC workgroups.? Provide oversight of provider based status compliance.? Other EMMC duties as assigned by the VP of Compliance and Privacy,including in support of other aspects of compliance program such asHIPAA, auditing, coding/billing, etc.** ****Physical Demands and Working Environment:**? Flexibility, dexterity, visual acuity, hearing acuity.? Ability to work at an ergonomically correct workstation, uses acomputer and keyboard, and answers the phone.? Moderate walking throughout the facility.? Light lifting of files and manuals, some bending to file.? May occasionally requiring donning and doffing of personal protectiveequipment while touring sterile environments.? May require temporary entry into tight spaces for purpose ofinspection and observation.? May occasionally require entry into sterile surgical environments toobserve surgical/medical procedures.? May occasionally require temporary entry into non-climate-controlledareas and areas where climate is controlled for reasons other thancomfort.? Requires the ability to travel to Northern Light Health memberorganizations as needed.***Note: the duties listed above reflect the majority of the essentialduties of this job and does not, nor is it intended to, reflect allessential duties that may be required for an incumbent in this job toperform.***
Associated topics: bilingual, family medicine physician, family practice physician, general practice, nocturnist, outpatient, physician md, practitioner, primary, urgent care

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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