Compliance Specialist (Hospital Survey Readiness Specialist)-CS3-SR29

Initial Posting Date:

02/20/2025

Application Deadline:

03/02/2025

Agency:

Oregon Health Authority

Salary Range:

$5,842 - $8,967

Position Type:

Employee

Position Title:

Compliance Specialist (Hospital Survey Readiness Specialist)-CS3-SR29

Job Description:

Compliance Specialist (Hospital Survey Readiness Specialist) (CS3) SR 29

The Oregon State Hospital, a division of the Oregon Health Authority has a fantastic opportunity for a Compliance Specialist, experienced in Facility Operations and Safety to join our excellent Standards & Compliance team, and work to advance their career. 

The Oregon State Hospital (OSH) is a psychiatric hospital that inspires hope, promotes safety, and supports recovery. OSH employs over 2,000 FTE and serves over 600 patients each day on two campuses. OSH provides therapeutic, evidence-based, patient-centered treatment focusing on patient recovery and community reintegration. 

The Standards and Compliance department is part of OSH's Quality Management team.  The Quality Management team consists of Performance Improvement, Data Analysis, and Incident Response System Investigations. Standards and Compliance provides regulatory compliance and accreditation oversight to OSH facilities, administers licensing and certification with the State of Oregon, supports staff at OSH in understanding regulatory compliance and serves as the point of contact for accreditation and regulatory oversight.

Within Standards and Compliance, this position is assigned a specialty area to focus their knowledge and expertise, in this case, facility operations. Within the assigned specialty area, the Compliance Specialist's purpose is to assure OSH is compliant with standards from internal and external entities that include, but are not limited to, the Joint Commission; Code of Federal Regulations (CFR), including Center for Medicare and Medicaid Services (CMS); the State Fire Marshal; Oregon Health Authority (OHA); Department of Administrative Services (DAS) and others; as well as compliance with Oregon Revised Statues (ORSs) and Oregon Administrative Rules (OARs).

Standard 40-hour work week, with an 8:00 a.m. start time. The position allows for a combination of onsite and remote work, with travel between both the Salem and Junction City, Oregon campuses as needed. The primary work location is the Salem campus of Oregon State Hospital.

The Oregon Health Authority is committed to:

• Eliminating health inequities in Oregon by 2030
• Becoming an anti-racist organization
• Developing and promoting culturally and linguistically appropriate programs, and
• Developing and retaining a diverse, inclusive, and equitable workforce that represents the diversity, cultures, strengths, and values of the people of Oregon.
• Click here to learn more about OHA’s mission, vision, and core values.

*This is a full-time permanent opportunity, represented by a union.

What you will do!

This Compliance Specialist (Hospital Survey Readiness Analyst) serves as a senior level professional, responsible for the coordination and overall duties related to ensuring compliance with federal, state, local laws, regulations, policies and accreditation standards of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), Oregon Revised Statutes (ORS), Oregon Administrative Rules (OAR), and internal standards, policies, and requirements. This work includes but is not limited to the review and resolution of the most complex compliance issues including developing goals, standards, policies, data collection tools, comprehensive corrective action plans, and trainings for staff related to compliance. Compliance situations vary greatly, and guidance is not always readily available.

This position reports to the Director of Standards and Compliance and works independently with significant discretion, minimal supervision and in collaboration with the Director, other department staff, and Quality Management leadership to provide professional expertise to Oregon State Hospital management and staff throughout the Oregon State Hospital system, in the completion of complex compliance-related activities as required by various Federal, State, and local regulatory agencies. This position also acts as backup to the Director of Standards and Compliance including program coordination, preparing compliance materials including but not limited to licenses, applications, completing documentation of tests/tracers/compliance reviews to databases, sentinel event reporting, audit responses, corrective action plans, and assessment reports as requested.

Standards and Compliance focuses on six program areas in a complex behavioral and hospital healthcare system:

• Hospital Survey Readiness
• Regulatory Review
• Compliance Culture Specialist
• Licensing, Waivers and Polices
• Billing Compliance
• Compliance Culture

The Compliance Specialists in Standards and Compliance are designated to support specific program area. This position is assigned to supporting OSH Facilities and Safety departments and performs the following:

Survey Readiness Functions

• Monitors Survey readiness activities, including but not limited to logistical survey planning, maintaining survey readiness files and operations plans, 18 Cross Functional Work Team status reports.
• Collaborates with departments in their survey readiness activities.
• Trains departments to build skill in responding to surveyors.
• Maintains knowledge of survey topics produced by The Joint Commission. Attends trainings and advises Standards & Compliance management of changes in survey practices.

Compliance & Consultative Functions

• Maintains knowledge of applicable regulatory standards, including but not limited to standards of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), Oregon Revised Statutes (ORS), Oregon Administrative Rules (OAR), and internal standards, policies, and requirements.
• Designs data collection tools followed by the in-depth collection, evaluation, analysis, and presentation of data related to compliance and regulatory functions.
• Provides technical consultation with management and staff regarding interpretation and/or application of often complex or difficult to define laws, regulations, rules, and/or policies.
• Performs focused, system, and program tracers, document, and compliance reviews of specific standards and/or regulations to determine compliance with accreditation standards, federal, state, and local rules and regulations.
• Investigates systems that are identified at risk of noncompliance and includes evaluation, coordination, tracking, and interpreting laws, rules or policies determined deficient.
• Determines potential courses of action including assisting management in development of corrective action plans and determining goals that are adequate to correct cited deficiencies and/or makes recommendations for establishing compliance.
• Assigns deficiencies cited and monitors corrective actions implemented to resolve instances of non-compliance using multiple tools including but not limited to databases such as AMP, etc.
• Instructs others, including management in the appropriate handling of regulatory complaints.
• Represents the Standards and Compliance Department on assigned committees, work groups, Cross Functional Work Teams, task forces, disciplines, programs, units and regulatory bodies.
• Maintains knowledge of all applicable sanctions and what level of violation equates to what level of sanction.
• Develops and maintains hospital system wide survey readiness materials in collaboration with division management and communications department.
• Conducts Intra-Cycle Monitoring (ICM) and mock survey activities as required by leadership. This includes working with designated contractors as needed and conducting independent internal mock surveys.
• Determines, documents, develops corrective actions, and reports appropriately if deficiencies in cited standards pose an immediate jeopardy to public, patients, or staff and identify which may be cited at standard or conditional levels, if problems are of an immediate and serious nature, or would create potential negative patient outcomes.
• Represents department in facilitating, compiling, and developing final materials for responding to case preparation requests and external audits.
• Facilitates development of department program goals, objectives, corrective action plans, and continuous improvement sheets at regularly scheduled team meetings.
• Identifies, develops, and delivers compliance-related training to staff as needed for compliance with current and new requirements.
• Responsible for reviewing policy updates to ensure compliance, developing comprehensive policy proposal reviews and/or recommending changes based on knowledge and interpretation of applicable standards.
• Acts as backup to the Director of Standards and Compliance including program coordination, preparing compliance materials including but not limited to licenses, applications, completing documentation of tests/tracers/compliance reviews to databases, sentinel event reporting, audit responses, corrective action plans, and assessment reports as requested.

Data Management and Reporting Functions

• Designs effective data collection tools.
• Conducts and compliance related data collection.
• Maintains spreadsheets, databases, and other data storage files.
• Updates related software such as Tracers with Accreditation Manager Plus (AMP) as assigned.
• Trains others to use Accreditation Manager Plus (AMP) and other documentation software as assigned.
• Prepares desk manuals with process maps and standard work for department and position.
• Maintains skills in Excel, Access, Power Point, Visio, and other applicable software packages.
• Submits regularly scheduled reports as requested or required by certifying bodies.
• Prepares technical summary guidelines for interpretation of laws, regulations, and policies to post on department website.
• Provides data related to compliance issues to hospital management and committees as approved.
• Ensures necessary compliance and regulatory documentation is updated in electronic and paper formats including rolling cart, etc.
• Reviews, develops, maintains, and reports program performance goals/metrics to track improvements leading to compliance with identified standards, and prepares metric sheets for use in various formats including but not limited to spreadsheets, dashboards, Primary Visual Display Boards (PVD), etc.

What's in it for you?

• Medical, vision, and dental benefits
• 11 paid holidays
• 8 hours of vacation per month, eligible to be used after 6 months of service.
• 8 hours of sick leave per month, eligible to be used as accrued.
• 24 hours of personal business leave per fiscal year, eligible to be used after 6 months of service.
• Pension and retirement programs 
• Opportunity to potentially receive loan forgiveness under the Public Service Loan Forgiveness Program (PSLF).
• Continuous growth and development opportunities
• Opportunities to serve your community and make an impact through meaningful work.
• A healthy work/life balance, including some remote options as well.

What we are looking for:

Minimum Qualifications

Five years’ experience doing administrative research that included compiling and evaluating facts to recommend management action or decide compliance or eligibility with program guidelines and regulations (facilities and workplace safety). Three of the five years must be above the technical support level.

OR

A Bachelor's Degree in Business or Public Administration, Public Health or other relevant field and two years of the specified experience, facilities and workplace safety.
 

*College-level course work may substitute for experience on the basis of 45-quarter units per year, up to a maximum of three years.

At least five years’ experience in:

• Center for Medicare and Medicaid Services (CMS) guidelines
• The Joint Commission standards pertaining to Hospital and/or Behavioral Health
• Applicable federal and state regulatory laws
• Computer software programs including Microsoft Office, PowerPoint, Adobe
• Medical/clinical records review
• Methods of organizational, program, and statistical analysis
• Use computer software to compile, analyze and report information
• Explain in writing and verbally, complex technical and legal material in understandable language to people of diverse education, language, and cultural backgrounds

REQUESTED SKILLS:

• Excellent written/verbal communication
• Must possess extensive knowledge of healthcare regulations, Centers for Medicare and Medicaid Services (CMS) and Code of Federal Regulations (CFR) guidelines and The Joint Commission (TJC) standards
• Experience in interpreting regulatory law, policies, and conducting compliance reviews/tracers
• Analytical thinking and the ability to organize work effectively and determine priorities
• Must work well independently and in a fun and professional team environment
• Experience implementing quality and continuous improvement methods such as lean, six-sigma, total quality management, etc. 
   

Working Conditions

This position is required to collaborate with all levels of the organization and with external divisions, offices, and agencies. Employee is required to regularly work closely with leadership, department directors, and hospital staff throughout the organization in all programs and campus locations across the state. The employee regularly interacts with persons outside the organization and frequently leads projects, workgroups, and other groups to complete work. The person in this position works with a high level of independence with minimum oversight under the general supervision of the department director.

General office environment with daily use of a personal computer, electronic mail, telephone, conference rooms. Access/use of telecommuting may be possible as supervisor deems necessary for business operations. Has limited contact with psychiatric patients. Requires daily use of stairs and elevators to access hospital units and official workstations.  Work hours subject to change with little notice. May be required to work hours that exceed regular schedule such as double shift in addition to regular schedule due to business need. This position serves both OSH Salem and Junction City campuses and may require travel between locations on an as needed basis. Must have a valid driver's license or other alternative method of transportation to perform state business.

Desired Attributes:

• Working knowledge of regulations relevant to hospital licensure, accreditation, and operations; basic knowledge of legislative requirements for hospital operations; and working knowledge of technical policies, procedures, and protocol development, application, and maintenance in an acute psychiatric hospital setting.
• Skills in applying general rules to specific problems and synthesizing information in a way appropriate for the situation and audience.
• Advanced writing and editing skills. Skills in communicating effectively in writing appropriate to the audience.
• Skills in developing collaborative working relationships with people across the organization and in other agencies, managing stressful situations, and mediating between groups and conflicting goals.
• Skills in communicating collaboratively with people to delegate work, establish boundaries for document quality or accuracy, and respond to complaints.
• Ability to listen and respond in a respectful, professional manner.
• Ability to reinterpret criticism into feedback to learn and improve effective work and systems.

How to Apply

PLEASE NOTE: Resumes, cover letters and all other documents must all be uploaded at one time. When uploading a resume, please upload any other documents in the same area/field.

The job application, resume, and a cover letter are required for this posting and should address the skills in this section clearly. Applications without the required documentation will not move forward in the selection process.

• Complete the online application
• Attach a resume (required)
• Attach a cover letter (required) of no more than two pages addressing the “What we are looking for?” section including required and preferred skills.

Attention current State of Oregon employees:

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To apply as a job rotation/developmental candidate, you must be currently employed by the State of Oregon (this includes regular status employees, who have completed trial service, as well as limited duration employees).

Help Your Application Rise to the Top!

Your candidate profile and resume are the perfect opportunity to highlight your interest in the position and showcase the amazing skills and experience, making you the best candidate for the position. Submissions will be screened for consistency of information and communication skills at the professional level (attention to detail, spelling, grammar, etc.).

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Please ensure you’ve provided a thorough and updated application as it pertains to the position for which you are applying. If you meet the minimum qualifications for the position, and are the successful candidate, you may qualify for work out of class. For further information, please visit the Pay Equity Project homepage.

PAY EQUITY

The Oregon Health Authority is committed to fair employment practices and non-discrimination, including pay equity for all employees. We do not discriminate based on protected class (race, sex, veteran status, disability, age, color, religion, national origin, marital status, sexual orientation) in the payment of wages or screen applicants on the basis of their current or past compensation. We determine salary by completing a review of your application materials to evaluate your related education, experience, and training for this position.

Questions/Need Help?

If you need assistance to participate in the application process, including an accommodation request under the American with Disabilities Act contact: Melissa Perez, SPHR at melissa.m.perez@oregon.oha.gov or 503-209-7058.

TTY users please use the Oregon Telecommunications Relay Service: 1-800-735-2900. For technical support, please call toll free 1-855-524-5627, for customer service assistance.

Additional Information

• Please monitor your Workday account to view all communication regarding your application. You must have a valid e-mail address to apply.
• Background Check: If you are offered employment, your offer will be contingent upon the positive outcome of an abuse check, criminal records check and driving records check.  The information will be shared with the Oregon Health Authority (OHA), Office of Human Resources (OHR). Any criminal or founded abuse history will be reviewed and could result in the withdrawal of the offer or termination of employment.
• Veterans: If you are a veteran, you may receive veteran’s preference. Click here for more information about veterans’ preference. To receive veterans' preference points, please submit the following required documentation when you apply:
• A copy of your DD214/DD215 form; OR a letter from the US Dept. of Veterans Affairs indicating you receive a non-service-connected pension for the five (5) point preference.
• A copy of your DD214/DD215 form; AND a copy of your veterans' disability preference letter from the Dept. of Veterans Affairs for the ten (10) point preference.
• Visa Sponsorship: We do not offer VISA sponsorships or transfers currently. You will be required to complete the US Department of Homeland Security's I-9 form confirming authorization to work in the United States within three days of hire.
• Please attach only the documents that are related to the position. Additional documents that are attached will not be reviewed.

Affirmative Action and Equal Opportunity

The Oregon Health Authority is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran or disabled status, genetic information, or any other protected class under state or federal law. In addition, we do not discriminate, or screen applicants based on current or past compensation. To learn more about OHA’s mission, vision, and core values, click here.

The Oregon Health Authority is an equal opportunity, affirmative action employer committed to workforce diversity.