Job Description

The Regional Compliance & Privacy Officer-Hospitals is a member of the OCCP with general duties and responsibilities related to being the focal point for implementing Steward Health Care System’s (Steward) Compliance & Privacy Program for approximately 2-5 community hospitals in a region.


This position reports directly to a Divisional System Deputy Compliance & Privacy Officer and indirectly to the Hospital Presidents/COOs.  The Regional Compliance & Privacy Officer-Hospitals needs to be a person of high integrity, and any other duties assigned should not be in conflict with the Steward’s compliance program goals and objectives.  This position will be based at one of the hospitals in the assigned region and will require some travel to the other assigned hospitals as well as other Steward locations.


The Regional Compliance & Privacy Officer is responsible for driving implementation of Steward’s Compliance Program at the hospital level. This position will be accessible to their assigned hospitals in order to implement and maintain the Compliance & Privacy Program and to provide guidance to hospital management teams.


The ideal candidate will:


  • Drive consistent application of Steward’s Code of Conduct and compliance policies across the assigned Steward hospitals.
  • Establish and fosters effective working relationships and builds credibility within the Steward hospitals to support a culture of compliance. 
  • Identify potential risk areas and assists the Steward hospitals with developing risk mitigation and/or corrective action plan strategies.  
  • Act as a consultative resource to assigned hospital leadership on issues concerning compliance and privacy matters, and provides recommendations to enhance policies, procedures and internal controls as needed. 
  • Ensure that information is provided to assigned hospital-level management to keep them current on the latest compliance program related risks and leading practices. 
  • Work with the OCCP leadership in the development and delivery of compliance and privacy training programs, ensuring all members of the assigned hospital workforce are knowledgeable of applicable laws, Steward’s Code of Conduct and Steward’s compliance policies. 
  • Ensure all identified issues are logged in the OCCP database (ComplyTrack) accurately and timely, and conducts regular documented follow up until issues are resolved.
  • Work collaboratively with appropriate Steward workforce members to resolve all compliance issues identified.  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 hospital meetings, including Compliance Committee meetings. 
  • Lead investigations or supervises investigations of compliance and privacy concerns at the assigned hospitals that are raised through the Compliance Support Line or other communication mechanisms. 
  • Under the direction of the Divisional System Deputy, Compliance and Privacy Officer, consults with the Office of General Counsel (OGC) as needed to resolve legal compliance issues.  Cooperates with 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. 
  • Manage communication, risk assessment and reporting responsibilities as it relates to identified federal and state data breach laws. 
  • Review conflict of interest disclosure forms for assigned hospitals to identify any concerns that may need to be brought to the attention of the System Deputy, Compliance & Privacy Officer and hospital leadership for follow-up or resolution
  • Participate in health care compliance and privacy professional organizations to stay abreast of privacy and corporate compliance developments and leading industry practices.
  • Attend and/or co-chairs entity-level Compliance Committee meetings as requested and ensures documentation of meeting is complete and timely.
  • Participate in periodic OCCP team meetings in order to ensure effective communication. 
  • As requested, actively participate in Steward committees as an OCCP representative.
  • Prepares individual entity and/or regional written activity reports, on a quarterly basis or as requested
  • Keep the Divisional System Deputy, Compliance and Privacy Officer informed of compliance program activities and issues on a timely basis.
  • Provide updates to assigned Steward hospital-level management on compliance & privacy program activities and issues on a regular basis (at least quarterly). ? Facilitates hospital based activity related to timely completion of designated OCCP Work Plan deliverables.
  • Collaborate and works effectively with other Regional Compliance & Privacy Officers and other OCCP team members to drive "operational excellence" (i.e., standardization, scalability, effectiveness and efficiency) system-wide.
  • Maintain time and effort reporting records as requested.
  • Demonstrate respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
    1. Commits to recognize and respect cultural diversity for all customers (internal and external).
    2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
  • Perform other duties as assigned.


Education:  A bachelor’s degree required.


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 a plus.


Certification/Licensure:  Certification in Healthcare Compliance (CHC) certification required. Certification in Healthcare Privacy Compliance (CHPC) preferred.


Software/Hardware:  Microsoft Outlook, Word, Excel, Internet Explorer and PowerPoint Skills Required. Microsoft Access Skills preferred.  Ability to effectively navigate electronic health records and hospital billing systems preferred.  Ability to research applicable Medicare, Medicaid and other compliance requirements is required.


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

Application Instructions

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