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Develops, initiates, maintains, and revises policies and procedures for the general operation of the compliance pro- gram and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Program.
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Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
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Collaborates with other departments (for example, Human Resources, Chief Security Officer, Health Information Management Director, and so on) to direct compliance issues to appropriate existing channels for investigation and resolution.
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Consults with General Counsel as needed to resolve difficult legal compliance issues.
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Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures.
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Develops and oversees a system for uniform handling of such violations.
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Acts as an independent review and evaluation body to ensure that compliance issues and concerns within the organization are being appropriately evaluated, investigated, and resolved.
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Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
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Identifies potential areas of compliance vulnerability and risk, develops and implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.
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Provides reports on a regular basis, and as directed or requested, keeps the Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.
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Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropri- ate or required.
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Establishes and provides direction and management of the compliance hotline.
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Institutes and maintains an effective compliance communication program for the organization, including promoting: (a) use of the compliance hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.
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Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees and ongoing training for all employees and managers.
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Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness.
Other Responsibilities: