POSITION SUMMARY Will provide strategic leadership, direction, and oversight of the Laguna Healthcare Corporation (LHC) Compliance, Quality & Risk Programs, encompassing all clinical, administrative, financial, and medical practice plan functions. This position is responsible for designing, implementing, and continuously improving enterprise-wide programs that ensure adherence to all federal, state, tribal, and accreditation standards. Serve as the primary authority on compliance matters, leads risk mitigation efforts, manages investigations, and champions a culture of ethics, accountability, and transparency. The Director collaborates with leadership, providers, and staff to promote a culture of continuous improvement, patient safety, and accountability. They oversee performance improvement initiatives, incident reporting systems, compliance activities, and risk mitigation strategies to enhance patient outcomes and organizational effectiveness. This position also plays a critical role in integrating culturally responsive care into quality frameworks, supporting health equity, and ensuring services reflect the values, traditions, and needs of the Tribal population served.
ESSENTIAL FUNCTIONS- Develop, implement, and oversee LHC's Compliance, Quality & Risk programs, policies, and procedures related to standards of conduct; healthcare laws; billing and reimbursement; fraud, waste, and abuse prevention; privacy and security; quality improvement and other compliance risk areas
- Lead and facilitate internal committees to drive strategic planning for these programs, setting long- and short-term goals, operational plans, and performance measures
- Conduct organization-wide quality and risk assessments to identify, prioritize, and mitigate compliance risks and improve overall patient outcomes
- Monitor compliance with healthcare laws, CMS/OIG regulations, HIPAA/HITECH, and Tribal requirements
- Oversee sanction screening of employees, contractors, and vendors; ensure organization-wide training on sanction monitoring processes. Ensure credentialing, privileging and provider enrollment program is effective
- Lead internal audits and compliance reviews to ensure adherence to payer rules, regulatory standards, and organizational policies
- Develop, in collaboration with the CMO, clinical care guidelines, as well as process and system guidelines
- Manage confidential reporting channels, including the LHC Compliance Hotline, ensuring proper documentation, investigation, and resolution
- Conduct or supervise compliance investigations; ensure/coordinate corrective actions with HR, legal counsel, leadership, and managers
- Serve as the organizational liaison with regulatory agencies during audits, investigations, and compliance inquiries
- Lead and mentor others in root cause analysis (RCA), healthcare failure mode and effects analysis (FMEA) and hazard vulnerability analysis (HVA) teams. Summarize risk management and patient safety data for appropriate evaluation and risk trend analysis
- Maintain detailed records of compliance efforts, investigative outcomes, and corrective action plans
- Provide written and verbal compliance reports to executive management, internal Quality Committee, the Board Compliance Committee and the LHC Board of Directors
- Develop and administer a robust, organization-wide compliance training and education program in conjunction managers and the HR department
- Lead communication initiatives to promote compliance awareness, ethical conduct, quality management and transparent reporting
- Provide ongoing consultation to staff and leadership on regulatory requirements and performance improvement measures
- Develop and coordinate processes to monitor quality of care. Identify opportunities to improve patient care, treatment and services by assisting to implement standard work
- Oversee accreditation preparation for review by regulatory agencies including AAAHC and/or Joint Commission, educate, and assist department supervisors to maintain appropriate policies and procedures to fulfill requirements and regulations
- Develop, monitor, and manage department budget
- Supervise and direct staff and consultants and ensure adequate systems, training and tools to support program goals achievement, performance management and corrective action
MINIMUM QUALIFICATIONSFive (5) years of progressive experience in healthcare compliance, quality or related healthcare roles. Bachelor Degree in Finance/Accounting, Business, Public or Healthcare Administration or related field of study from an accredited college or university. Master's Degree preferred.
Certified Professional Compliance Officer (CPCO) preferred, Certified in Healthcare Compliance (CHC), Certified in Healthcare Privacy Compliance (CHPC), or Certified Compliance & Ethics Professional (CCEP) or equivalent compliance certification
, or eligible for and certification obtained within 12 months as condition of hire. Quality Management certification preferred.
MANDATORY KNOWLEDGE, SKILLS, ABILITIES and COMPETENCIES with proficiency levelsEthical Integrity & Professionalism - Advanced1. Demonstrates unwavering commitment to confidentiality, transparency, and ethical conduct.
2. Consistently models organizational values and establishes an ethical compliance culture.
3. Guides organizational decision-making through an ethics-centered approach.
Regulatory & Compliance Expertise - Advanced1. Interprets and applies federal, state, and Tribal healthcare regulations with precision.
2. Advises leadership on complex regulatory issues and emerging compliance risks.
3. Ensures organizational alignment with OIG, CMS, HIPAA/HITECH, and other regulatory standards.
Analytical & Critical Thinking - Advanced1. Uses advanced analytical methods to identify trends, risks, and system vulnerabilities.
2. Evaluates complex scenarios, synthesizes large volumes of information, and provides clear recommendations.
3. Leads continuous improvement initiatives using data-driven insights.
Investigation & Problem-Solving - Advanced- Conducts or oversees thorough investigations into compliance concerns
- Demonstrates strong evidence analysis skills and draws objective, well-supported conclusions
- Designs and monitors corrective action plans to ensure sustainable resolution
Leadership & Influence - Advanced1. Leads cross-functional teams and committees with confidence and clarity.
2. Influences organizational behavior through effective communication, coaching, and ethical leadership.
3. Builds trust and credibility with executives, clinical leaders, and staff.
Communication & Interpersonal Effectiveness - Advanced1. Clearly communicates complex regulatory concepts to varied audiences.
2. Prepares high-quality written reports and delivers professional presentations.
3. Maintains strong interpersonal relationships across diverse stakeholder groups.
Training & Education Development - Intermediate to Advanced1. Designs tailored compliance training programs for all workforce levels.
2. Assesses training effectiveness and adjusts content to address knowledge gaps.
3. Promotes consistent awareness of compliance responsibilities.
Project & Program Management - Intermediate to Advanced1. Manages multiple projects simultaneously while meeting deadlines.
2. Develops strategic and operational plans for the Compliance Program.
3. Implements structured processes for tracking progress and outcomes.
Risk Management & Continuous Improvement - Advanced1. Conducts comprehensive risk assessments and ongoing monitoring activities.
2. Identifies compliance vulnerabilities and implements preventative strategies.
3. Leads continuous improvement efforts across systems, policies, and internal controls.
Technical & Systems Proficiency - Intermediate1. Utilizes compliance software, databases, and Microsoft Office applications effectively.
2. Works collaboratively with IT and privacy teams to support data security practices.
3. Applies technology solutions to enhance documentation, reporting, and workflow efficiency.
PERFORMANCE EXPECTATIONSIn performance of their respective tasks and duties, an employee of Laguna Healthcare Corporation is expected to conform to the following:
1. Fully uphold all principles of confidentiality and patient care.
2. Adhere to all professional and ethical behavior standards of the healthcare industry.
3. Maintain all licensures and certifications required of position.
4. Interact in an honest, trustworthy and respectful manner with patients, employees, visitors and vendors.
5. Participate in leadership and/or board meetings, departmental staff meetings, quality management activities and educational programs as required.
6. Comply with Laguna Healthcare Corporation policies and procedures.
7. Demonstrate and comply with LHC values:
COMPASSION, HONESTY, ACCOUNTABILITY, RESPECT AND TRUST.8. Maintain a valid, insurable driver's license.
TRIBAL PREFERENCELHC will apply "Indian Preference" as an employment criterion and not a "racial classification." The Laguna Healthcare Corporation has implemented a Tribal Preference in Employment Policy. Pursuant to this Policy, applicants who possess the knowledge, skills, and abilities required by this position, and who are enrolled members of the Pueblo of Laguna will be given primary preference in hiring and employment for this position. Members of other Federally recognized Indian Tribes will be given secondary preference for hiring and employment after providing proof of Tribal membership.
CONFIDENTIALITYAll employees must fully uphold all principles of confidentiality. This position will have access to sensitive information and a breach of these principles will be grounds for immediate termination
Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed. 
