Director Non-clinical

POSITION SUMMARY:

• The Compliance & Privacy Officer is a member of the OCCP at Good Samaritan Medical Center with general duties and responsibilities related to being the focal point for implementing Steward Health Care System’s (Steward) Compliance & Privacy Program for the specified Region.
• This position reports directly to the Good Samaritan Medical Center’s President. The Compliance & Privacy Officer needs to be a person of high integrity, and any other duties assigned should not conflict with the Steward’s compliance program goals and objectives. This position will be based at Good Samaritan Medical Center.
• The Compliance & Privacy Officer is responsible for driving implementation of Steward’s Compliance Program at the hospital/clinic level
• This position is responsible for driving compliance program “operational excellence” (i.e., standardization, scalability, effectiveness, and efficiency) related to investigations, reporting, monitoring, education, and corrective action plans to Good Samaritan Medical Center.

KEY RESPONSIBILITIES:

• Drives consistent application of Steward’s Code of Conduct and compliance policies to Good Samaritan Medical Center.
• Ensures that information is provided to Good Samaritan Medical Center’s entity-level management to keep them current on the latest compliance program related risks and leading practices
• Assists the OCCP in conducting a risk assessment to support the overall annual Compliance Plan
• Review’s conflict of interest disclosure forms for Good Samaritan Medical Center to identify any concerns that may need to be brought to the attention of the System Deputy, Compliance & Privacy Officer and entity leadership for follow-up or resolution
• Management responsibilities include but are not limited to hiring, training, development, and performance management, as well as continuous improvement of workflow/communication within the team based on leading practice techniques.
• Assists with professional development of OCCP staff through in-service meetings, education programs, conferences, etc.
• Develop and manage on-going data analytics efforts, based on the annual Work Plan
• Ensures quality assurance through an internal process on each investigation
• Maintains documentation of methods used and individuals involved in verifying compliance; documented identified issues, corrective actions taken, and improvements implemented
• Assists with the development and delivery of compliance training programs, as assigned
• Ensures all identified issues are logged in the OCCP database (Comply Track) accurately and timely and conducts regular documented follow up until issues are resolved
• Leads investigations or supervises investigations of compliance and privacy concerns at Good Samaritan Medical Center that are raised through the various reporting mechanisms
• Under the direction of the Senior Vice President, Chief Compliance Officer, Good Samaritan President, consults with the Office of General Counsel (OGC), as needed, to resolve legal compliance issues
• Monitors the implementation status of management’s corrective action plans in response to identified compliance and privacy issues and facilitates regular discussion on open topics at meetings, including Compliance Committee meetings
• Assists with preparing written reports, on a quarterly basis or as requested, to keep the Regional System Deputy, informed of compliance activities and issues for Good Samaritan Medical Center on a timely basis. Also, assists with providing reports to Good Samaritan Medical Center entity-level management on compliance program activities and issues on a regular basis (at least quarterly)
• Interacts with employees at all levels, always demonstrating impartiality and fairness
• Establishes and retains a cooperative relationship with Medicare Administrative Contractors and others to understand applicable Medicare and other third-party payor requirements
• Demonstrates a knowledge and understanding of Steward’s policies and procedures and applicable regulatory requirements.
• Maintains a library of appropriate reference material that will facilitate the understanding of and compliance with applicable requirements
• Establishes and fosters effective working relationships and builds credibility within the Good Samaritan Medical Center to support a culture of compliance
• Identifies potential risk areas on an ongoing basis and assists the Good Samaritan Medical Center/clinics with developing risk mitigation and/or corrective action plan strategies
• Under the direction of the Regional System Deputy, Compliance & Privacy Officer acts as a consultative resource on issues concerning compliance, and provides recommendations to enhance policies, procedures, and internal controls, as needed
• Keeps the Regional System Deputy informed of compliance program activities and issues on a timely basis
• Disseminates key industry regulator audit updates such as CMS, OIG, etc. to OCCP team
• Cooperates with the regulators (e.g., CMS, OIG, OCR, State Attorney General, etc.) and other parties, as appropriate, in connection with any privacy or compliance inquiries, audits, or investigations
• Manages communication, risk assessment, and reporting responsibilities as it relates to identified federal and state data breach laws
• Participates in health care compliance professional organizations to stay abreast of compliance developments and leading industry practices
• Represents the OCCP through participation in various Steward committees and work groups as assigned
• Attends and/or co-chairs entity-level Compliance Committee meetings as requested and ensures documentation of meeting is complete and timely
• Participates in periodic OCCP team meetings to ensure effective communication
• Maintains time and effort reporting records, as assigned
• Collaborates and works effectively with other Compliance & Privacy Officers and other OCCP team members to drive “operational excellence” (i.e., standardization, scalability, effectiveness, and efficiency) system-wide
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment
• Commits to recognize and respect cultural diversity for all customers (internal and external)
• Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs, and ages, utilizing interpreters when needed
• Performs other duties, as assigned.

REQUIRED KNOWLEDGE & SKILLS:

• Knowledge and experience with hospital related health care laws and regulations (e.g., Anti-Kickback Statute, Stark Law, etc.), and hospital inpatient and outpatient coding and billing compliance required
• Familiarity with federal and state privacy laws and regulations required
• Familiarity with operational, financial, and information technology security procedures and regulations a must
• Strong oral/written communication and presentation skills a must
• Strong leadership, organizational, interpersonal, and analytical skills, and the ability to function effectively in a fast-paced environment
• Ability to prioritize and plan work independently
• Ability to interact with employees at all levels
• Effectively work with and coordinate the activities of external consultants and legal counsel, as assigned
• Ability to anticipate potential issues and proactively respond
• Good judgment and problem-solving skills
• Team player
• Ability to maintain confidentiality

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

I. Education: A bachelor’s degree required

II. Experience: A minimum of 5 years’ experience in a health care environment to include demonstrated management and leadership in compliance and privacy. For profit health care experience is a plus

III. Certification/Licensure Software/Hardware: Microsoft Outlook, Word, Excel, Internet Explorer and PowerPoint

Skills Required. Microsoft Access Skills preferred. Ability to effectively navigate electronic health records and billing systems. Ability to research applicable Medicare, Medicaid and other compliance requirements is required

IV. Other: Travel Requirements:

• The ability to travel regionally and nationally
• Must have a valid driver's license, provide own transportation, and be able to travel to Steward locations using a variety of modes of transportation

Salary range: $150k - $180k