Director of Administration and Compliance - First Choice Community Health Centers

SUMMARY: The Director of Administration & Compliance (DAC) is directly responsible for the day-to-day operations of all First Choice Community Health Centers (FCCHC) medical and dental sites. The DAC is a member of the Senior Management Team and is also responsible for directing key areas related to operations, performance management, compliance and quality, business development, strategic and financial planning, as well as special projects.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

Key Performance Area I: Site Operations Management

1. Responsible for performance of each First Choice Sites, as measured by site-level performance indicators and targets; 
2. Creates and maintains systems and processes necessary to successfully manage the organization's current activities and its projected growth;
3. Maintains sound plan of corporate organization, establishing consistent application of corporate policies at each site; ensure adequate management development and to provide for capable management succession;
4. Develops and installs procedures and controls to affect both lateral and vertical two-way communication and adequate information flow across the organization, leveraging both verbal, electronic, and conferencing resources; 
5. Establishes operating policies consistent with CEO expectations and corporate policies and objectives and ensures their execution, using a balanced scorecard measurement system;
6. Evaluates the results of overall operations regularly and systematically and reports these results, as well as any concerns, to the Chief Executive Officer.
7. Regularly visits all sites to promote collaboration and communication, assess staff performance, monitor operational efficiency, and assess compliance with established standards of practice and standards of care; validates performance with hard data and routine “spot checks” in key areas. Each site should be visited a minimum of once per week, either by COCO or the Performance Improvement Coordinator. Address and follow-up on any issues which are identified and report resulting actions.

​Key Performance Area II: Performance Management of Subordinate Employees

1. Oversees managers who direct site-level and department activities that implement the organization's policies; positions managed include Performance Improvement Coordinator, Team Leaders (intra-site), IT Specialist, and Environmental Specialist. (Note: The DAC is ultimately responsible for the performance of the individuals in these positions);
2. Directly supervises sites and oversees the daily operation of all sites, implementing policies and procedures, and expectations set forth by the CEO and Board of Directors;
3. Develops work plan strategies in support of organizational goals and objectives for the sites in conjunction with the Team Leaders that are consistent with those of FCCHC. Regularly monitors progress in meeting objectives and revises plans and priorities, as necessary; Assists managers in the development of their work plans per timeliness and content standards;
4. Provides oversight for maintenance/housekeeping to ensure centers are fully operational and meeting established standards with respect to all duties required of housekeeping and maintenance staff; Conduct periodic (weekly) documented walk-through as is relates to established standards;
5. Develops and maintains Facility Maintenance Plan;
6. Meets regularly with clinical and administrative staff to assure coordination of activities, adherence to health and business plan, and consistent application thereof;
7. Responsible for the timely and accurate completion of Performance Evaluations and other personnel actions for direct reports per established procedures;
8. Assists managers in the application of corporate policies, procedures, and practices that comply with local, state and federal laws and regulations.

Key Performance Area III: Quality, CQI, and Process Improvement

1. Directly or indirectly (via Performance Improvement Coordinator) responsible for all improvement initiatives, including those related to patient flow, patient satisfaction, productivity improvement, and/or process improvement, in support of measurable objectives. Conducts and documents improvement initiatives/plan;
2. Ensures performance indicators are accurately measured (measurement systems analysis) and reported. Develops and maintains organizational scorecard reporting system; Submits monthly report to CEO with action plan;
3. Ensures that each FCCHC site maintains a daily productivity goal of a minimum of 36 or more patients a day; identifies root causes of deficits and takes corrective action in coordination with site staff and the Director of Strategic Marketing and Corporate Development;
4. Selects high ROI and/or patient-focused projects for improvement, quantifies impact using performance metrics which are in alignment with strategic goals and objectives;
5. Utilizes the CQI process to identify opportunities for improved patient flow, improved access-to-care, and scheduling process improvement, and reviews same with CEO and appropriate Department Heads. Follows up on patient complaints to maintain positive image; Charter and facilitate cross-functional process improvement and/or compliance team;
6. Maintains open communication with the Chief Medical Officer and Department leadership to ensure that the non-clinical administrative operational processes are appropriately integrated into the clinical areas to promote operational efficiency in the provision of patient care.

Key Performance Area V: Strategic, Operating, Financial, and Program Planning

1. Develops and supports the implementation of organizational Operating Plan in coordination with other members of the management team;
2. Assists the Senior Management Team in defining short and long-term goals and develops strategies that will improve the operational efficiency of FCCHC;
3. Support the establishment of the new FCCHC delivery sites (mobile or standing), and the efficient, effective, and compliant operations thereof;
4. Prepares monthly reports for the Board and is actively involved in the strategic planning activities;
5. Monitors expenditures and budget variances related to operations in conjunction with the CFO. Takes corrective action, as necessary;
6. Assists in completion of all Monthly/Quarterly/Annual reconciliations and other required reporting as required by governing agencies;
7. Assists CFO in completion of all annual cost reports, annual financial audits, annual UDS report, and/or any other required annual governmental reporting.

Key Performance Area VI: Corporate Compliance

1. Serves as the Chief Compliance Officer responsible for the auditing, monitoring and evaluating components of the compliance program;
2. Oversees development and monitoring of Risk Management, Crisis Management, Business Continuity and Disaster Recovery Plans;
3. Serves as the Health Insurance Portability Act (HIPAA), and Health Information Technology for Economic and Clinical Health (HITECH) officer, ensuring that regulations for privacy, security and transaction and codes are maintained; Creating a reporting mechanism to be submitted to the CEO as part monthly activities reporting;
4. Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Compliance Program;
5. Collaborates with other departments (e.g., Risk Management, Internal Audit, HR, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the corporate attorney or approved resources as needed to resolve difficult legal compliance issues;
6. Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating and/or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations;
7. Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated and resolved. Routinely conducts random audits, directly or through Performance Improvement Coordinator, of sites to assess compliance and quality standards are being maintained across all areas. Reports violations to responsible manager and CEO to address root causes;
8. Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to prevent or deal with similar situations in the future; Develops and implements training program as needed to address improvement opportunities; 
9. Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required;
10. Ensures that independent contractors and/or agents who furnish services to the corporation are aware of and in compliance with the requirements of the corporation’s Compliance Program with respect to coding, billing, marketing, and/or protected health information (HIPAA/HITECH); and/or other regulations.
11. 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;
12. Will ensure that FCCHC remains in compliance with all corporate compliance programs, HIPAA, HITECH, and other regulations. Notifies (verbally and in writing) employees of updates in policies and/or procedures, and assesses knowledge thereof.

Key Performance Area VII: CEO Support/Special Projects

1. Meets regularly with the CEO to keep abreast of any issues or concerns as they relate to the overall effectiveness/efficiency and future of the organization;
2. Assists the CEO, DSMCD, and CFO with grant writing;
3. Serves as a liaison for all construction and renovation projects;
4. Prepares monthly reports for the Board of Directors, by direction of the Chief Executive Officer;
5. Assists the DSMCD with the CEO Scorecard Report;
6. Completes other duties as assigned.

COMPETENCIES: The competencies listed below are representative of the knowledge, skills, and/or abilities which must be consistently demonstrated for this job. Each of the following competencies will be evaluated as part of Performance Evaluation according to the following scale: Core Competencies: Chief Operations and Compliance Officer Performance Evaluation Score (Score Rating Targets: 90.0 or Higher= Exceeds Standard, 80.0 – 89.0 = Meets Standard, 70.0 - 79.0 = Minor Improvement Needed, Below 70.0= Developmental Opportunity). 

1. Accuracy of Work - Completes all work with high quality and attention to detail. Avoids re-work and/or frequent need for corrections.
2. Adaptable to Change - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
3. Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
4. Coachability – Responds to coaching feedback in a positive manner; desires to grow in role; follows through on improvement plans resulting in observable and measurable improvement.
5. Communication to Person Reporting – Communicates frequently (as-needed) with person reporting to all necessary information, including project status, work-related issues or concerns, as well as concerns, questions, or suggestions. Is accessible and responds quickly to calls and e-mail attempts.
6. Communication to Subordinates – Is available and accessible to subordinate employees; keeps subordinates informed as it relates to company information. Able to tactfully assess and confront poor performance; quickly identifies issues needing corrective action; reports such actions to CEO. Treats all subordinate employees fairly and objectively.
7. Compliance – Consistently complies with all established company standard operating processes and procedures.
8. Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue; Conserves organizational resources.
9. Customer Service – Responds promptly to internal and/or external customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
10. Dependability and Follow-through - Follows through on requests and/or instructions (the first time), responds to management direction; Takes responsibility for own actions; Keeps commitments; provides status updates without requests.
11. Effectiveness in Role – Ultimately effective in contributing to measurable strategic goals and objectives of the organization.
12. Ethical Standards – Understands and models organizational values; Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically;
13. Flexibility – Flexible in terms of role and schedule.
14. Initiative - Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities; Asks for and offers help when needed.
15. Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things; Able to tactfully confront performance issues.
16. Judgment - Displays willingness to make decisions; Models an effective decision-making process; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
17. Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.
18. Motivation – Puts forth full effort; Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence; Takes calculated risks to accomplish goals.
19. Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.
20. Problem Solving Skills - Identifies and resolves problems in a timely and effective manner; Addresses root-causes of recurrent problems; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics; Seeks help when needed.
21. Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments; Maintains a professional appearance.
22. Quantity and Productivity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
23. Strategic Thinking – Understands mission, strategic goals, objectives, and measures and understands how their area impacts organization; Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses.
24. Teamwork with Peers and Other Functions - Balances functional and organizational responsibilities; Contributes to upstream and downstream processes; Works well with peers, superiors, and subordinates.
25. Technical Skills – Understands the technical aspects of functional area; Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others; Stays current with industry/technical changes.
26. Timeliness of Work Completion – Completes work on-time and on-schedule; prioritizes, provides frequent unsolicited status updates regarding more involved projects.
27. Verbal and Presentation Skills – Speaks clearly and effectively; able to effectively prepare for and present to a group.
28. Written Communication - Writes clearly and informatively (grammar and spelling); Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

EDUCATION and/or EXPERIENCE: Combined clinical and business management education, with graduate-level education and concentration in management and/operations . Ability to prioritize and effectively execute the goals and initiatives of the organization. Self-motivated, detail oriented and able to both effectively delegate and communicate to employees at all levels of the organization. General to advanced certifiable knowledge of SixSigma, Lean, Business Process Improvement and other process improvement methodologies, with field experience demonstrating measurable results preferred.

LANGUAGE SKILLS: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

MATHEMATICAL SKILLS: Ability to apply basic concepts of mathematics and computations.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. OTHER SKILLS AND ABILITIES: Use of computer skills to include working knowledge of all software available to employees and the ability to train employees on usage of software. Familiarity with effective use of computerized accounting, billing, patient information, and electronic medical records software. Must be able to use other equipment such as a fax, copier and calculator. Good organizational skills and the ability to perform numerous tasks simultaneously in a fast-paced office environment. Good analytical skills, attention to details, sense of personal responsibility for work performance and a professional attitude. The ability to adhere to policies and procedures is a must.

PHYSICAL/MENTAL DEMANDS: The physical/mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disability to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear, sit, and use hands to handle or feel objects, tools, or controls. The employee is occasionally required to stand, walk, climb, balance on two feet, stoop, kneel, crouch, or reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Mental demands include the ability to learn, adapt to changes, pay close attention to details, exercise discretion and good judgment, develop options and solutions to crisis and problems, gather and analyze facts, courteous and professional behavior, deal with stressful situations and adhere to company policies and procedures.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

RISK CLASSIFICATION LEVEL: I- (Job classification level in which employees have minimal risk to blood borne pathogens).

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