Compliance Analyst serves as the primary focal point for all compliance related activities within one or more of the primary focus areas within compliance to include but not limited to auditing, monitoring, patient privacy, information security, billing, coding, research, conflict of interest, policy and procedure development/oversight, and the overall compliance program for Billings Clinic. Position is responsible for researching and remaining informed on related compliance regulations, laws and guidelines, implementing compliance plans, developing policies, training and auditing. Position is responsible for audits, training and orientation relative to assigned areas. Position is responsible to facilitate and/or participate in committees related to compliance. The Compliance Analyst works closely with the Corporate Compliance and Integrity Officer, Director of Compliance and Privacy, Research Integrity Officer, Compliance Committees, Information Services, Patient Financial Services, Coding Resources, Quality, Risk Management, Human Resources, Legal and Billings Clinic leadership groups to ensure compliance guidelines are adhered to and high-risk areas are identified and addressed. Responsible for quality of the service and all deliverables. ## Compliance Analyst reports to the department Manager/Supervisor.
Essential Job Functions

• GENERAL
Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and Compliance Department and the eight elements of the Compliance Program.

• POLICIES
Participates in the development, maintenance, communication, interpretation, education and oversight of policies, procedures and protocols in accordance with organizational Leadership, Compliance Committee, legal and/or regulatory requirements.
Participates in the monitoring and enforcement of policies, procedures, legal and regulatory requirements.
Provides clarity, advice and guidance on policy compliance efforts.
Serves as an advocate and resource for all levels of Billings Clinic leadership and staff. Works with leadership in assessing and addressing assigned compliance program concerns and assists with recommendations to address needs. Assists in identifying and resolving various operational issues.
Participates in the development of new policies and procedures and the modifications of existing policies and procedures for all departments at an administrative level.

• STRUCTURE
Provides assistance and support to the Compliance Officer/Director in a variety of capacities to include but not limited to:
Participates in the development, implementation, review and evaluation of the compliance program.
Participates in the day-to-day operations of the compliance program and pursuit of compliance objectives.
Participates in and supports initiatives to identify risks.
Participates in and supports initiatives to address corrective action plans for identified compliance issues
Participates in and /or facilitates compliance related committees, project tasks teams, and/or improvement initiatives.

• LINES OF COMMUNICATION
Communicates to assigned areas about the established Billings Clinic systems in place for soliciting information and employee concerns related to Billings Clinic compliance program, compliance concerns, and compliance related questions. Participates in the development and maintenance of compliance communication programs (newsletters) and employee reporting channels.
Participates in regular compliance reporting of key metrics to Board of Directors and other diverse audiences and/or committee structures to assure they are generally informed of compliance issues and developments, and with the intent of improving the prevention and/or detection of any noncompliance.
Acts as a resource and liaison with external governmental/regulatory agency representatives to facilitate reviews and investigations or required reporting. Provides consulting support to regional Affiliate to address the same concerns.
Participates in the development of newsletters and other tools to communicate compliance requirements.

• AUDITING & MONITORING
As part of Billings Clinic audit plan, develops an audit/review schedule and work plan for assigned departments/areas. Ensures that the audit/review schedule is maintained and that recommendations and deficiencies identified in the audit/review are implemented and resolved. Monitors the effectiveness of the compliance program on a regular basis, including a comprehensive review conducted at least annually. Ensuring adequate internal controls are in place to prevent and detect significant instances or patterns of illegal, unethical or improper conduct. Audits items as identified by Billings Clinic Compliance Committee related to the OIG Work Plan and Billings Clinic risk areas.
Arrange and coordinate internal audits for the purpose of monitoring and detecting non-compliance with applicable laws and compliance program requirements.
Prepares reports documenting auditing findings, conclusions, suggested corrective actions, recommendations, areas of risk and communicates/reports information regularly to the Compliance Director.
Ensures identified non-compliance detections are fully investigated and a corrective action plan is developed and carried out. Responsible for ensure compliance is achieved and sustained.
Acts as a project manager and ensure that appropriate timing, resources, and sequencing of work efforts are applied to create the project deliverables within a given timeframe and budget.
Participates in the continual improvement of the Compliance Program and implements changes on an ongoing basis to improve the prevention/detection of any non-compliance, as well as changes in needs of Billings Clinic, federal laws or regulatory requirements.
Documents corporate compliance efforts and progress made in establishing methods and/or processes to improve the efficiency and quality of services and/or to prevent or reduce vulnerability to illegal, unethical or improper conduct, fraud, abuse and waste. Reports regularly to Compliance Director and organizational Compliance Committee.

•RESPONDING TO REPORTED OFFENSES
Works with the Compliance Director to ensure the development and maintenance of a structure that encourages and enables employees to report violations to the Compliance Team and/or Compliance Officer, including the effective use of a “hot line” without fear of retaliation. Ensures the system is adequately publicized.
Works collaboratively with all members of the Compliance Team to ensure all allegations of non-compliance are fully investigated and responded to promptly. Acts as a resource and liaison for external audits, compliance reviews or investigations.
Documents investigation efforts and progress made in establishing methods and/or processes to improve the efficiency and quality of services and/or to prevent or reduce vulnerability to illegal, unethical or improper conduct, fraud, abuse and waste. Reports regularly to Compliance Director and organizational Compliance Committee.
Provides assistance and consulting support for regional Affiliates.

•DISCIPLINE & ACCOUNTABILITY
Works collaboratively with Billings Clinic Leadership, Human Resources and Legal to ensure mechanisms are in place for disciplining instances of non-compliance appropriate to the nature and extent of the deviation, and ensure consistency in the application of the disciplinary action.
Works with Compliance Officer, Compliance Director and Legal Counsel to report any instances of non-compliance to external agencies and/or regulatory entities as appropriate.
Works with Human Resources to ensure a work force with high ethical standards, including the establishment of minimum standards for conducting appropriate background and reference checks on potential employees.
Supports the Compliance Officer, Research Integrity Officer, Compliance Director and other members of Senior Leadership as necessary to address non-compliant behavior related to non-employed workforce members, members of the Medical Staff, contract staff, providers with privileges to practice, etc.

•TRAINING
Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements. Responsible for maintaining knowledge of relevant compliance issues, laws, regulations and trends.
Participates in the development and coordination of a multifaceted educational and training program that focuses on the elements of the Compliance Program and seeks to ensure that all employees, volunteers, affiliated professionals, contractors, to ensure awareness and understanding of policies and protocols and to mitigate risk areas.
Participates in the assessment and prioritization of the need for training and education.
Shares knowledge and expertise within the Compliance Team to promote cross-training, back-up and general awareness.

• MEASURING PROGRAM EFFECTIVENESS
Establishes and administers a process for documenting and tracking of all complaints, action taken, and any needed follow-up. Incorporates the use of technology and efficient work flow processes for creating documentation.
Documents corporate compliance efforts and progress made in establishing methods and/or processes to improve the efficiency and quality of services and/or to prevent or reduce vulnerability to illegal, unethical or improper conduct, fraud, abuse and waste. Reports regularly to Compliance Director and organizational compliance committees.

• INFORMATION SYSTEMS SUPPORT
Serves as the primary technology resource for the implementation and on-going development of compliance information systems (i.e., Compliance 360 modules, COI software, etc.). Coordinates closely with Billings Clinic Leadership, staff members, Information Services staff, key stakeholders and software vendors for the planning, analysis, design, implementation, evaluation and support for business solutions and resources needed to meet business goals and objectives.
Acts as a liaison and expert resource with the user community and software vendor to identify problems and concerns regarding the overall performance of the compliance information systems. Researches, analyzes and makes recommendations and/or initiates corrective action to resolve problems with the internal functionality of the system and/or integration of information between systems. Provides the software vendor with recommendations for system enhancements, detailed information regarding technical or functionality problems and coordinates implementation of recommended fixes received.
Provides technical support and acts as a resource responding to procedural questions regarding system functionality and technical interaction with other Billings Clinic system applications. Develops and executes plans for evaluation of the informatics solution including measurement, disseminating results, and recommending changes to the informatics system. Applies advanced designs to informatics solutions based on capabilities of software and usability principles. Provides expert analytical techniques to current work processes and data flow and develops process redesign recommendations leading to a solution and/or functional system requirements. Duties include project management and requirements gathering and analysis for strategic and/or tactical projects, system testing, conversion planning, facilitation of organizational change, coordination and performance of daily support/maintenance activities, program development for orientation/training of new users and on-going education and training for established users, branch locations, affiliate and/or managed sites, etc.

• GENERAL DUTIES
Utilizes performance improvement principles to assess and improve quality particularly as it relates to the processes in the areas assigned. Utilizes operational excellence tools.
Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements. Maintains/builds outside network of colleagues.
Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
Performs other duties as assigned or needed to meet the needs of the department/organization. May conduct other special projects as assigned.