Compliance & Risk Management Director

Mosaic Health Careers • Muskegon, MI

8h • Onsite

About The Position

Muskegon Family Care is looking for a Full- Time Compliance & Risk Management Director to join our Supportive & Collaborative Team. Under the guidance of the Chief Executive Officer and in collaboration with the MFC Board of Directors, the Compliance and Risk Management Officer is responsible for developing, implementing, and maintaining programs that ensure organizational compliance and effective risk mitigation. This includes identifying, assessing, and managing financial, operational, legal, and regulatory risks that could impact the organization’s performance or reputation. The officer ensures adherence to HIPAA, FTCA, CARF, and HRSA requirements, and directs the collection and analysis of data to meet compliance objectives. The position also oversees policy enforcement and contributes to improving staff and patient safety.

Requirements

• Bachelor’s degree in business administration, public health, healthcare administration, nursing, or related field required.
• Minimum five (5) years of experience in healthcare compliance or risk management, or equivalent combination of education and experience.

Nice To Haves

• Certifications such as CHC (Certified in Healthcare Compliance) or CPHRM (Certified Professional in Healthcare Risk Management) preferred.

Responsibilities

• Develop, implement, and monitor the annual Health Care Risk Management Training Plan for all staff members based on identified areas and activities of the highest clinical risk for the health center (including, but not limited to, obstetrical procedures and infection control) and any non-clinical trainings appropriate for health center staff (including HIPAA medical record confidentiality requirements)
• Complete an Annual Risk Management Report for the Board of Directors and key management staff.
• Conduct risk assessments and develop risk mitigation strategies, policies, and procedures. Monitor and report on the effectiveness of those strategies.
• Ensure proper incident tracking, peer review, root cause analysis, and facility monthly compliance and risk management committee meetings.
• Communicate risk status and compliance updates to stakeholders and leadership.
• Provide training and coaching to managers and staff on compliance and risk-related processes and emerging issues.
• Document, analysis, and address breaches, clinically related complaints and “near misses” reported by employees, patients, and other individuals related to risk management goals.
• Ensure that credentialing, privileging, and claims history reviews comply with FTCA and HRSA standards.
• Maintain working knowledge of HRSA and MDHHS grant requirements and reporting obligations.
• Build and maintain programs to ensure compliance with federal, state, and local regulations, including FTCA, HIPAA, and CARF standards.
• Review and maintain all organizational contracts and Business Associate Agreements.
• Monitor all employee-related incidents and accidents and ensure OSHA reporting and documentation compliance.
• Collaborate with the Facilities Manager, HR Compliance Coordinator, and Security Administrator to update the Emergency Management Plan and related protocols.
• Serve as the organization’s Privacy Officer and ensure compliance with HIPAA regulations.
• Provide consultation to leadership and department heads regarding legal or regulatory changes.
• Revise the compliance, risk, and privacy programs as needed to remain current with legal, regulatory, and ethical changes.
• Review and propose changes to policies and procedures in accordance with system requirements.
• Contribute to strategic planning and budget development as needed.
• Support interdepartmental coordination and resolve compliance-related issues.
• Perform all other duties as assigned.
• Identifies and assesses compliance risks and concerns.
• Maintain monthly HIPAA compliance audit.
• Cooperate with U.S Department of Health and Human Services (HHS) Office of Civil Rights (OCR)00 and other federal and state entities, in any privacy program audits, inquiries or investigations.
• Serves as an internal subject matter expert on HIPAA, maintains current knowledge of HIPAA laws and regulations, and any other applicable federal and state privacy laws or regulations.
• Ensures that the company is in overall compliance with HIPAA guidelines and directives.
• Monitors entity operations, systems and employees for security compliance.
• Ensure compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the organizations workforce, extended workforce and for all business associates, in cooperation with Human Resources, the Security Official, administration and legal counsel as applicable.
• Monitors the process for receiving, documenting, tracking, investigating, and acting on all complaints concerning the organization’s privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel.
• Drafts and disseminates the Privacy Notice required by the Privacy Rule.
• Reviews all contracts under which access to confidential data is given to outside entities, bring those contracts into compliance with the Privacy Rule, and ensure that confidential data is adequately protected when such access is granted.
• Conducts periodic privacy audits and takes remedial action as necessary.

Benefits

• Paid Time Off
• Holiday Pay
• Vendor Discounts
• Tuition Reimbursement up to $1,500 annually
• 401K- safe harbor contribution, we match 100% up to 3% employee contribution: 50% for the next 2% employee contribution
• Student Loan Forgiveness: Working for Muskegon Family Care may allow you to participate in programs that forgive the balance of qualifying student loans. Information/eligibility is available from the U.S. Department of Education.

What This Job Offers

• Job Type: Full-time
• Career Level: Director