The Role
Leads the corporate compliance program across skilled nursing, long-term acute care, assisted living, and corporate operations. Responsibilities include regulatory monitoring, compliance audits, risk assessments, investigations, hotline oversight, HIPAA privacy, employee training, survey support, corrective action tracking, and executive and Board reporting. The role collaborates with legal, risk, finance, clinical, and facility leadership to mitigate healthcare regulatory and operational risks.
Summary Generated by Built In
LEGACY HEALTHCARE MANAGEMENT
Job Description
Title: Corporate Compliance Officer
Reports to: CEO
Effective Date: Review Date: N/A
Position SummaryThe Corporate Compliance Officer is responsible for developing, implementing, and overseeing the organization's Corporate Compliance Program across all Skilled Nursing Facilities (SNFs), Long-Term Acute Care Hospitals (LTACHs), Assisted Living facilities, and affiliated corporate operations. This position ensures compliance with all applicable federal, state, and local laws and regulations governing healthcare operations, including Medicare, Medicaid, HIPAA, CMS Conditions of Participation, state licensing requirements, and the Office of Inspector General (OIG) Compliance Program Guidance.The Corporate Compliance Officer serves as an independent resource to Executive Leadership and the Board of Directors, promoting a culture of ethics, integrity, accountability, and regulatory compliance while mitigating organizational risk.Essential Duties and ResponsibilitiesCorporate Compliance Program- Develop, implement, maintain, and continuously improve the Corporate Compliance Program.
- Establish and monitor compliance policies, procedures, and internal controls.
- Conduct annual compliance risk assessments and develop corrective action plans.
- Monitor adherence to corporate policies and regulatory requirements across all facilities.
- Ensure compliance with OIG guidance, CMS regulations, state licensing requirements, and accreditation standards.
- Prepare compliance reports for Executive Leadership and the Board of Directors.
- Monitor changes in federal and state healthcare regulations and ensure organizational compliance.
- Interpret regulatory requirements and communicate operational impacts to leadership.
- Oversee compliance with:
- Medicare and Medicaid regulations
- CMS Conditions of Participation
- State licensing requirements
- HIPAA Privacy and Security Rules
- Anti-Kickback Statute
- Stark Law
- False Claims Act
- Corporate Integrity Agreements (if applicable)
- OSHA and workplace safety regulations
- Ensure required governmental reporting is completed accurately and timely.
- Develop and execute annual compliance audit plans.
- Conduct internal audits of:
- Medical records
- Billing and reimbursement
- Documentation
- HIPAA compliance
- Admissions and discharge practices
- Quality measures
- Resident rights
- Financial and operational controls
- Monitor implementation of corrective action plans.
- Track recurring compliance issues and identify systemic risks.
- Manage confidential compliance investigations.
- Oversee the corporate compliance hotline and reporting process.
- Investigate allegations involving:
- Fraud
- Waste
- Abuse
- HIPAA violations
- Resident abuse or neglect
- Ethical misconduct
- Billing irregularities
- Regulatory violations
- Coordinate investigations with Human Resources, Legal Counsel, Risk Management, and Executive Leadership.
- Maintain confidential investigative files and documentation.
- Develop and administer corporate compliance education programs.
- Ensure annual compliance and ethics training for all employees.
- Provide regulatory education to Executive Leadership and facility administrators.
- Educate department leaders regarding changes in healthcare regulations and best practices.
- Oversee the organization's HIPAA Privacy and Compliance Program.
- Investigate privacy breaches and security incidents.
- Ensure appropriate reporting of HIPAA violations.
- Monitor implementation of corrective actions following privacy incidents.
- Identify operational and regulatory risks.
- Collaborate with Risk Management, Clinical Leadership, Finance, and Legal Counsel to reduce organizational exposure.
- Participate in quality assurance and performance improvement initiatives.
- Recommend policy revisions to improve compliance and reduce liability.
- Assist facilities during state and federal surveys.
- Coordinate responses to regulatory agencies.
- Review Plans of Correction to ensure regulatory compliance.
- Monitor corrective actions following surveys or investigations.
- Prepare quarterly compliance reports for Executive Leadership.
- Present compliance findings, trends, and recommendations to senior leadership and the Board.
- Maintain documentation demonstrating the effectiveness of the Compliance Program.
- Bachelor's degree in healthcare administration, Nursing, Business Administration, Law, or related field required.
- Master's degree preferred.
- Minimum of five years of progressively responsible healthcare compliance experience.
- Minimum of three years in a leadership or corporate compliance role.
- Experience with Skilled Nursing Facilities, Long-Term Acute Care Hospitals, or post-acute healthcare organizations required.
- Experience with healthcare investigations, audits, and regulatory compliance.
- Extensive knowledge of:
- Medicare and Medicaid regulations
- CMS Conditions of Participation
- State survey process
- HIPAA Privacy and Security Rules
- OIG Compliance Program Guidance
- False Claims Act
- Anti-Kickback Statute
- Stark Law
- Healthcare fraud prevention
- Strong investigative and analytical skills.
- Experience conducting compliance audits and risk assessments.
- Excellent written and verbal communication skills.
- Ability to prepare executive-level reports and presentations.
- Strong organizational and project management skills.
- High level of integrity, professionalism, and discretion.
- Ability to work independently while collaborating with Executive Leadership.
- Certified in Healthcare Compliance (CHC)
- Certified Compliance and Ethics Professional (CCEP)
- Registered Nurse (RN) or Licensed Nursing Home Administrator (LNHA) preferred but not required.
- Ability to travel regularly between corporate offices and assigned facilities.
- Ability to sit, stand, walk, and work on a computer for extended periods.
- Occasional lifting of up to 20 pounds.
Skills Required
- Bachelor's degree in healthcare administration, nursing, business administration, law, or a related field
- Master's degree
- At least five years of progressively responsible healthcare compliance experience
- At least three years of leadership or corporate compliance experience
- Experience with skilled nursing facilities, long-term acute care hospitals, or post-acute healthcare organizations
- Experience conducting healthcare investigations, audits, and regulatory compliance activities
- Knowledge of Medicare and Medicaid regulations, CMS Conditions of Participation, state surveys, HIPAA, OIG guidance, False Claims Act, Anti-Kickback Statute, Stark Law, and healthcare fraud prevention
- Certified in Healthcare Compliance (CHC)
- Certified Compliance and Ethics Professional (CCEP)
- Registered Nurse (RN) or Licensed Nursing Home Administrator (LNHA)
- Ability to travel regularly between corporate offices and assigned facilities
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The Company
What We Do
The first privately owned Long-term Acute Care hospital in Michigan, located within McLaren Oakland Hospital. Mission: To provide quality, compassionate cost-effective care to the medically-complex patient to optimize their physical, emotional and spiritual well-being. Description What are long-term acute care hospitals? Long-term acute care hospitals (LTACHs) are facilities that specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis but no longer require intensive care or extensive diagnostic procedures. These patients are typically discharged from the intensive care units and require more care than they can receive in a rehabilitation center, skilled nursing facility, or at home. Where are LTACHs located? LTACHs often are housed within the walls of an acute care hospital but function independently. LTACHs must be licensed independently and have their own governing body. LTACHs may also exist as a stand-alone facility. What are the benefits of LTACHs? Because LTACHs are able to focus their energy and resources at a limited number of specialized treatments with minimal overhead, they are able to provide more cost-effective care than if these same patients were kept in acute care facilities. What types of patients are seen in LTACHs? Under Medicare, the patient must need more than 25 days of hospitalization. The average length of stay of a person in an LTACH is approximately 30 days. The types of patients typically seen in LTACHs include those requiring: ■ Prolonged ventilator use or weaning ■ Ongoing dialysis for chronic renal failure ■ Intensive respiratory care ■ Multiple IV medications or transfusions ■ Complex wound care/care for burns
