Job Title:
Governance and Compliance
Specialist (GCS)
FLSA Status: Exempt
Grant Funded: N/A Grant Number: N/A
Grant Position N/A Grant End Date: N/A
Reports To: Compliance Manager Union Position: N/A
Approved By:
Chief of HR, Legal, and
Compliance Officer
Department: Human Resources
Approved
Date:
10/24/24 Jobs Supervised: No
OUR MISSION: is to eliminate health disparities and foster community well-being by providing and
promoting the highest quality care in Los Angeles, San Bernardino, and Riverside Counties.
OUR VISION: St. John's Community Health will be a leader, catalyst, and model for the best care, long-
term community health improvements, and sustainable, health-enhancing system and structures in
Southern California.
OUR CORE VALUES
Dignity
We honor and respect every person we encounter-whether patient, colleague, or community member-
as a valued part of the human family.
Excellence
We support and champion the best standard of care, personal and professional growth, accountability,
creativity, teamwork, and a steadfast commitment to quality.
Well-being
We promote and advocate for the full integration of our patients' physical and mental health in order to
enable them to participate in their own health improvement and become active and responsible members
of a vibrant and just community.
Social Justice
We collaborate with others to develop systems, organizations, and programs to advance equity and fairness
in allocating community resources, and to empower and address the needs of all community members,
especially the most vulnerable and disadvantaged members.
JOB SUMMARY
As the Governance and Compliance Specialist at St. John's Community Health (SJCH), you are
responsible for ensuring that SJCH's policies and procedures comply with regulatory requirements and
industry best practices. You will work with other departments, such as legal, IT, and audit, to develop and
implement strategies to mitigate risk and maintain compliance. Additionally, you will provide analysis,
post-award services, and oversight to ensure compliance with grant-specific requirements; and serve as a
resource for staff of grant-funded programs for fiscal and programmatic compliance matters. Works
collaboratively to ensure staff are in compliance with the rules and regulations of regulatory agencies; that
company policies and procedures are being followed, and that behavior in the organization meets the
company's Standards of Conduct. The Governance and Compliance Specialist will also play a key role in
supporting the privacy compliance functions.
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ESSENTIAL DUTIES AND RESPONSIBILITIES
Performs a combination, but not necessarily all, of the following duties:
• Monitor and interpret federal, state, and local healthcare laws. This includes regulations related to
patient privacy (HIPAA), billing and coding (CMS regulations), fraud and abuse laws, etc.
• Responsible for the oversight of our organization's grant auditing process.
• Support business owners by providing review and recommendations to Corrective Action Plans.
• Review reports and financial data and contribute to the policies, procedures, and training to
ensure fiscal responsibility.
• Works closely with various departments including but not limited to HR, legal, finance, operations,
and clinical teams to promote a culture of compliance.
• Monitor, review, and provide guidance on federal and state regulations impacting privacy relates
initiatives.
• Conduct privacy compliance investigations.
• Contribute to the ongoing development and refinement of our privacy initiatives, actively
participating in privacy projects and audits.
• Ensure compliance with grant and contract requirements.
• Assist in the planning, design, implementation, and support of financial systems, related policies,
and processes needed to identify and manage the revenue and expenditures of the organization
and its various components.
• Prepare and/or review information and reports for internal and external stakeholders.
• Become knowledgeable of grant guidelines and expectations and advise programs on
implementation and ongoing efforts to ensure compliance.
• Analyze and evaluate contract and grant budgets for correct calculation of expenditure categories
such as salaries, percent of effort, salary adjustment increases, fringe benefits, indirect costs,
materials, and equipment.
• Conduct routine compliance reviews of grant programs.
• Conduct research, evaluate, and present options for the selection of contractors/subrecipients
according to the federal procurement and internal processes.
• Contribute to continuously improving internal grant management systems.
• Ensure all regulatory and/or grant-related training requirements are met and documented.
• Monitors the performance of the Compliance Programs and related activities on a continuing
basis, taking appropriate steps to improve its effectiveness.
• Maintains record of changes and archived copies for potential compliance and/or risk inquiries.
• Provide support for regulatory audits from the Health Resources Service Administration (HRSA),
Federal Tort Claims Act (FTCA), Operational Site Visit (OSV) and any third-party audits.
• Conducts on-site spot audits and coordinates with the Quality team.
• Monitors, and as necessary, coordinates compliance activities of other departments to remain
abreast of the status of all compliance activities and to identify trends.
• Identifies potential areas of compliance vulnerability and develops/implements corrective action
plans for resolution of problematic issues, and provides general guidance on how to avoid or deal
with similar situations in the future.
• Maintain strict confidentiality about individual health center findings and proprietary information.
• Travel between sites will be required.
• Performs all and any additional duties as assigned.
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Responsibility to Team - actively support assigned team/department by participating in and supporting
all team/departmental initiatives, proactively communicating with supervision, meeting assigned goals and
objectives, and committing to embracing process improvement initiatives.
Responsibility to Organization - actively support SJCH by consistently meeting St. John's Mission,
Vision, and Values; modeling positive interactions with patients, staff, and community; keeping informed of
internal (e.g., policies and procedures) and external (e.g., legal or political matters) which may affect
business.
Additional Duties - as assigned.
For Grant Funded Positions - if position is grant funded, grant specific duties which may be in addition
to the above are attached with employee attestation herewith.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential
functions.
Education, Experience, and Knowledge
• 3-5 years' experience in regulatory compliance in a healthcare organization
• Strong interpersonal skills with a proven ability to work well with individuals at all levels of an
organization.
• Excellent oral and written communication skills.
• Strong attention to detail.
• Excellent organizational skills with a proven ability to multi-task and work well under deadline
pressure.
• Advanced knowledge of Microsoft Office applications.
• A bachelor's degree or 3 years of relevant experience in compliance in healthcare.
• Certification in healthcare compliance is preferred (CHC).
Additional Requirements:
• Valid driver's license and reliable transportation.
• Ability to be covered by car insurance as required.
• Ability to drive and travel by car as needed.
• Flexibility to travel between Los Angeles, San Bernardino, and Riverside Counties as needed.
Language Skills
Ability to read, analyze and interpret general business periodicals, professional journals, technical
procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure
manuals. Ability to effectively present information and respond to questions from groups of managers,
clients, customers, and the general public.
Reasoning Ability
Ability to define problems, collect data, establish facts, and draw valid conclusions. Synthesize complex or
diverse information. Ability to interpret an extensive variety of technical instructions in mathematical or
diagram form and deal with several abstract and concrete variables. Ability to interpret situations,
characteristics, behavior, etc. and respond appropriately.
Computer Skills
To perform this job successfully, an individual should have knowledge of MS Outlook, MS Excel, MS Word,
and Internet software. Electronic Health Records experience preferred.
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PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to
successfully perform the essential functions of this job. Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential functions.
Must possess mobility to work in a standard office setting and use standard office equipment, including a
computer; to operate a motor vehicle and to visit various CCHPP institutions and meeting sites; vision to
read printed materials and a computer screen; and hearing and speech to communicate in person, before
groups, and over the telephone. This is primarily a sedentary office classification although standing in
work areas and walking between work areas may be required. Finger dexterity is needed to access,
enter, and retrieve data using a computer keyboard or calculator and to operate standard office
equipment. Positions in this classification occasionally bend, stoop, kneel, reach, push, and pull drawers
open and closed to retrieve and file information. Employees must possess the ability to lift, carry, push,
and pull materials and objects weighing up to 25 pounds.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters
while performing the essential functions of this job. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee establishes and maintains effective work relationships
with co-workers and customers, maintains regular attendance, understands and carries out a variety of oral
and written instructions, has knowledge of proper English usage, grammar, punctuation, spelling, and
vocabulary, has the ability to learn office principles, practices, and methods, understands filing systems,
including numerical, alphabetical, and chronological, learns a variety of procedures, policies, and services
of the assigned work unit or program, performs assigned duties with efficiency and accuracy and maintains
confidentiality.
The employee will be working in a normal office environment with exposure to moderate noise, dust,
temperature, etc. During community meetings and outreach activities an employee may be subjected to a
variety of locations and situations including community centers and large meeting rooms; this may involve
varying noise levels, temperature, dust, or other environmental differences.
NOTE
The statements herein are intended to describe the general nature and level of work performed by
employees, but is not a complete list of responsibilities, duties, and skills required of personnel so classified.
It is not to be constructed as an exhaustive statement for essential functions, responsibilities, or
requirements. Furthermore, they do not establish a contract for employment and are subject to change at
the discretion of the employer.
I understand the essential functions of this position and I am able to perform the functions of this position
with or without accommodation.
Signature
Print Name Date