Licensing and compliance officer-Chitrakoot/Kashi/Bareiily

The Licensing and Compliance Officer is responsible for overseeing and ensuring that the hospital complies with all applicable local, state, and federal laws, healthcare regulations, and licensing requirements. This includes maintaining current licenses, preparing for audits, implementing compliance programs, and ensuring staff are informed of legal and regulatory updates.

Key Duties & Responsibilities:

• Regulatory Adherence:

• Stay up-to-date on all relevant federal and state healthcare laws and regulations, including but not limited to:
• Health Insurance Portability and Accountability Act (HIPAA)
• Centers for Medicare & Medicaid Services (CMS) regulations
• Stark Law and Anti-Kickback Statute
• False Claims Act
• State-specific healthcare licensing and operational regulations
• Liaise with government authorities and regulatory agencies to ensure timely submission of documentation and address any inquiries or issues.

• Licensing & Accreditation:

• Oversee the end-to-end licensing process for the hospital, including all departments, facilities, and services (e.g., pharmacy, lab, surgery centers, pathology and biomedical waste).
• Manage all licensing applications, renewals, and updates with regulatory authorities.
• Ensure compliance with standards set by accreditation bodies (e.g., The Joint Commission).
• Collaborate with internal departments to ensure policies and procedures comply with current regulations.
• Maintain accurate records of all licenses, permits, and certifications.
• Conduct internal audits to assess compliance and recommend corrective actions where needed.
• Develop and deliver compliance training to staff.
• Assist in responding to regulatory inquiries, audits, and inspections.
• Prepare reports for senior management on compliance metrics and issues.
• Stay current on changes in laws and regulations that affect the organizations operations.

• Internal Audits & Monitoring:

• Conduct regular internal audits and risk assessments to identify potential areas of non-compliance.
• Monitor daily operations to ensure staff adherence to policies and procedures.
• Review medical billing, coding, and documentation practices for accuracy and compliance.

• Training & Education:

• Create and deliver compliance-training programs for new and existing staff across all departments.
• Educate employees on ethical standards and legal requirements, fostering a culture of compliance.
• Communicate any regulatory changes to relevant personnel and update internal policies accordingly.

• Investigation & Remediation:

• Investigate all reported or suspected compliance violations, including billing fraud, data breaches, and unethical conduct.
• Develop and implement corrective action plans to address issues and prevent recurrence.
• Serve as the primary point of contact for external audits and regulatory inquiries.

• Record Keeping:

• Maintain meticulous and up-to-date records of all compliance activities, including training records, audit results, and investigation reports.

• Collaboration:

• Work closely with hospital leadership, department heads, legal counsel, and human resources to ensure a cohesive and organization-wide approach to compliance.

• Deliverables & Accountability

  We expect that under your leadership:
• Meticulously reviewing documents, policies, and regulations and ensure accurate record keeping.
• Must demonstrate the highest level of ethical standards and professional conduct and dealing in the good faith of the hospital.
• In depth knowledge of the compliance and legal requirements of the hospital as per the state and central rules.

Please email updated cvs to tanumita.roy@3pointhrm.in