Compliance Specialist
Massachusetts General Hospital, Boston, MA, United States
Summary
Responsible for supporting the implementation and maintenance of the hospital's compliance program including conducting audits, providing training, monitoring compliance activities, and assisting with investigations to promote a culture of ethical conduct and mitigate compliance risks within the organization.
Essential Functions
Assist in developing, implementing, and maintaining the hospital's compliance program, including policies, procedures, and protocols.
Conduct periodic audits of hospital departments and processes to assess compliance with policies and identify areas for improvement.
Assist departments in understanding and implementing compliance policies, ensuring consistency and adherence throughout the organization.
Support the reporting and investigation of compliance-related incidents and potential violations.
Assist in monitoring compliance activities, analyzing data, and preparing compliance reports for presentation to senior management and relevant committees.
Participate in compliance committee meetings, providing updates on compliance activities and contributing to discussions on compliance matters.
Reporting to the Clinical Compliance Manager, Central Sterile Processing & Supply (CSPS), and receiving direction from the Director of Operational Alignment & High Reliability; the Compliance Specialist will be responsible for independent acquisition, analysis, and reporting of data to support the CSPS Department and HLDS Program.
Interact with business leaders at all levels, including physicians, finance, sterile processing nursing, administrative directors and managers, and PHS resources to execute initiatives.
Work independently and collaboratively to locate and validate data, identify data requirements, and communicate data specifications to team members and leaders.
Manage resources associated with projects and collaborate with the Sterile Processing Department and support projects involving procedural services and MGB initiatives.
Act as a critical participant in the evolution and continued development of the High-Level Disinfection and Sterilization Program.
Participate in the hospital-wide Interdisciplinary Tracer Program, develop documentation systems, implement unified weekly and monthly reports, and attend Task Force meetings.
Ensure assessments are catalogued for all active reprocessing locations and develop comprehensive remediation plans.
Use risk management practices throughout projects.
Gather, compile, and report metrics and data for routine and ad hoc reporting.
Support the MGB and Procedural Services Committees, lead the implementation of the information system SPDR, and provide training to data analysts.
Develop skills in EPIC and SPM instrument tracking, use data visualization tools, and create reporting/analytic solutions to assess business impact.
Education Bachelor's Degree Related Field of Study required.
Experience Experience in compliance, legal, or a related field. 2-3 years required.
Knowledge, Skills and Abilities
Knowledge of relevant laws and regulations applicable to the industry or sector (e.g., financial, healthcare, technology).
Familiarity with compliance frameworks and best practices.
Excellent attention to detail and analytical skills.
Strong written and verbal communication skills.
Ability to work collaboratively and independently as needed.
Proficiency in Microsoft Office and other relevant software applications.
Physical Requirements
Standing Occasionally (3-33%)
Walking Occasionally (3-33%)
Sitting Constantly (67-100%)
Lifting Occasionally (3-33%) 20lbs - 35lbsCarrying Occasionally (3-33%) 20lbs - 35lbs
Pushing Rarely (Less than 2%)
Pulling Rarely (Less than 2%)
Climbing Rarely (Less than 2%)
Balancing Occasionally (3-33%)
Stooping Occasionally (3-33%)
Kneeling Rarely (Less than 2%)
Crouching Rarely (Less than 2%)
Crawling Rarely (Less than 2%)
Reaching Occasionally (3-33%)
Gross Manipulation (Handling) Constantly (67-100%)
Fine Manipulation (Fingering) Frequently (34-66%)
Feeling Constantly (67-100%)
Foot Use Rarely (Less than 2%)
Vision - Far Constantly (67-100%)
Vision - Near Constantly (67-100%)
Talking Constantly (67-100%)
Hearing Constantly (67-100%)
Equal Opportunity Employer The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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Essential Functions
Assist in developing, implementing, and maintaining the hospital's compliance program, including policies, procedures, and protocols.
Conduct periodic audits of hospital departments and processes to assess compliance with policies and identify areas for improvement.
Assist departments in understanding and implementing compliance policies, ensuring consistency and adherence throughout the organization.
Support the reporting and investigation of compliance-related incidents and potential violations.
Assist in monitoring compliance activities, analyzing data, and preparing compliance reports for presentation to senior management and relevant committees.
Participate in compliance committee meetings, providing updates on compliance activities and contributing to discussions on compliance matters.
Reporting to the Clinical Compliance Manager, Central Sterile Processing & Supply (CSPS), and receiving direction from the Director of Operational Alignment & High Reliability; the Compliance Specialist will be responsible for independent acquisition, analysis, and reporting of data to support the CSPS Department and HLDS Program.
Interact with business leaders at all levels, including physicians, finance, sterile processing nursing, administrative directors and managers, and PHS resources to execute initiatives.
Work independently and collaboratively to locate and validate data, identify data requirements, and communicate data specifications to team members and leaders.
Manage resources associated with projects and collaborate with the Sterile Processing Department and support projects involving procedural services and MGB initiatives.
Act as a critical participant in the evolution and continued development of the High-Level Disinfection and Sterilization Program.
Participate in the hospital-wide Interdisciplinary Tracer Program, develop documentation systems, implement unified weekly and monthly reports, and attend Task Force meetings.
Ensure assessments are catalogued for all active reprocessing locations and develop comprehensive remediation plans.
Use risk management practices throughout projects.
Gather, compile, and report metrics and data for routine and ad hoc reporting.
Support the MGB and Procedural Services Committees, lead the implementation of the information system SPDR, and provide training to data analysts.
Develop skills in EPIC and SPM instrument tracking, use data visualization tools, and create reporting/analytic solutions to assess business impact.
Education Bachelor's Degree Related Field of Study required.
Experience Experience in compliance, legal, or a related field. 2-3 years required.
Knowledge, Skills and Abilities
Knowledge of relevant laws and regulations applicable to the industry or sector (e.g., financial, healthcare, technology).
Familiarity with compliance frameworks and best practices.
Excellent attention to detail and analytical skills.
Strong written and verbal communication skills.
Ability to work collaboratively and independently as needed.
Proficiency in Microsoft Office and other relevant software applications.
Physical Requirements
Standing Occasionally (3-33%)
Walking Occasionally (3-33%)
Sitting Constantly (67-100%)
Lifting Occasionally (3-33%) 20lbs - 35lbsCarrying Occasionally (3-33%) 20lbs - 35lbs
Pushing Rarely (Less than 2%)
Pulling Rarely (Less than 2%)
Climbing Rarely (Less than 2%)
Balancing Occasionally (3-33%)
Stooping Occasionally (3-33%)
Kneeling Rarely (Less than 2%)
Crouching Rarely (Less than 2%)
Crawling Rarely (Less than 2%)
Reaching Occasionally (3-33%)
Gross Manipulation (Handling) Constantly (67-100%)
Fine Manipulation (Fingering) Frequently (34-66%)
Feeling Constantly (67-100%)
Foot Use Rarely (Less than 2%)
Vision - Far Constantly (67-100%)
Vision - Near Constantly (67-100%)
Talking Constantly (67-100%)
Hearing Constantly (67-100%)
Equal Opportunity Employer The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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