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Compliance and Privacy Officer, Ontario, OR



Ontario, OR

March 28, 2017

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Compliance and Privacy Officer - (QA1100)

Job Title Compliance and Privacy Officer

Job Description


Acts as Compliance and Privacy Officer for the organization. Responsible for the development, day-to-day management and oversight of the ethics and compliance program, and for conducting and coordinating quality and compliance review activities of behavioral health inpatient, residential, and outpatient services for the organization. This is an exempt program management position which reports to the Lifeways CEO with access to the Lifeways Board.


The position shall be responsible for the following:

  1. Reporting to the board of directors and to the CEO on a regular basis on the efforts to develop and implement an effective ethics and compliance program.
  2. Coordinating the efforts of the compliance committee and the responsible departments and programs in the development, implementation and oversight of the Program and all compliance activities.
  3. Day to day management of the ethics and compliance unit.
  4. Coordinating the efforts of management and the Board to enforce, and revise as necessary, the Lifeways Code of Conduct.
  5. Coordinating the efforts of the compliance committee to develop the annual compliance plan.
  6. Developing and implementing a training program that includes:
    • An agency-wide training on the Program and the Code of Conduct
    • Incorporation of an ethics and compliance curriculum into the orientation program for all new employees
    • On-going training for employees working in high risk positions or departments within Lifeways. The purpose of the training will be to build and/or maintain the skill level of these employees in their areas of responsibility.
  7. Communicating to employees the importance of their reporting suspected wrongdoing to Lifeways and to develop alternative reporting mechanisms for them to do this, including a hotline for reporting suspected misconduct confidentially or anonymously.
  8. Ensuring that the Lifeways management team, including the human resource manager, have:
    • Developed appropriate procedures for ensuring that Lifeways does not hire or continue to employ individuals who have been excluded from the federal health care programs.
    • Mechanisms in place to reasonably determine that individuals that are hired or are currently working for Lifeways are ethical individuals who understand Lifeways’ commitment to “zero tolerance” of inappropriate, illegal and unethical behavior.
    • Developed and implemented appropriate disciplinary policy, that it is consistently and fairly applied at all levels of the organization, for compliance related infractions, including and up to termination of employment.
  9. Conducting or coordinating investigations into compliance related issues or reports to ensure that there is adequate follow-up, corrective action (including disciplinary action), and that appropriate documentation is developed and retained.
  10. In conjunction with the CEO and the Lifeways Board, consulting with legal counsel to determine the appropriate response of the organization to detected violations including the scope and protocol for investigations, documentation standards, reports, corrective action and appropriate follow-up including voluntary paybacks or voluntary disclosures to third parties, and direct reports to the board of directors.
  11. Working with management in the development and implementation of appropriate internal controls and measurements to reasonably ensure that the activities of the organization comply with the law, regulation and rules that govern the work of the organization and that of non-compliance and improper conduct can be detected.
  12. Developing a records management system for the compliance program that ensures that all relevant documents being maintained or developed by the office, in either paper or electronic format, are secure, accurate, complete and evaluated on a regular basis for destruction or retention.
  13. Developing and conducting an annual review of the Program to evaluate its effectiveness in promoting compliance within Lifeways.
  14. Promoting an organizational culture that encourages ethical conduct and a commitment to compliance with the law.
  15. Overseeing periodic compliance risk assessments to identify the highest priority risk exposures, and developing a plan for mitigating those risks.


Compliance: The primary responsibility is to implement, manage and monitor the Lifeways compliance program, in collaboration with Executive Management.

Quality Assurance: Develop, implement and conduct systematic continuous assessment of clinical documentation, quality of service and client outcomes.

Privacy Officer: The responsibilities of the Privacy Officer include coordination of HIPAA privacy compliance activities.

Job Requirements


Bachelor’s Degree (Master’s Degree preferred) in human services, business administration, or related field. At least five years’ experience working in a regulated environment and a minimum of two years of direct clinical experience in behavioral health is preferred. A history of working collaboratively with, and earning the respect and confidence of organizational staff members and experience as an effective educator/trainer. Experience auditing organizational records and documentation is also preferred. Certified Healthcare Compliance Certification or equivalency is required within 30 months of hire.


Must have, or develop an expert knowledge of national and state laws and regulations including but not limited to False Claims Act, Physician Self-Referral (Stark), Anti-Kickback Stature, Health Insurance Portability Act (HIPAA), Health Information Technology for Economic and Clinical Health (HITECH); and State regulations applicable to treatment and reimbursement under MediCaid and other third party payers; basic utilization review/survey procedures and techniques; medical and surgical, mental health, or alcohol and drug diagnoses, procedures, and types of treatment; and basic principles and practices of supervision.

Ability to:

  1. Prepare and maintain accurate records;
  2. Interpret rules and regulations;
  3. Prepare clear and concise reports using correct grammar, punctuation, and spelling;
  4. Maintain objectivity and confidentiality;
  5. Gather and analyze data, draw conclusions, and make recommendations;
  6. Communicate effectively, both one on one and in groups; and
  7. Use word processing and spreadsheet applications.


Ability to pass drug screen and background check.


Travel is required. Work is performed in an office environment. Requires keyboarding, ability to hear voice conversation. May require some walking, bending and lifting to 20 pounds.

Location Ontario - Ontario, OR 97914 US (Primary)

Category Administrative / Executive

Job Type Full Time

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