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Organization TypePublic Interest
Years of Experience
Date Last Verified
ProfileDirector of Compliance, Chief Compliance Officer Duties: Plays a crucial role in developing, implementing and maintaining an effective system-wide compliance program. Designs and manages the organization’s compliance efforts, including investigating compliance-related issues, administration and enforcement of the organization’s compliance plan and policies, and coordinating, monitoring, and auditing various organizational activities that relate to or implicate potential compliance issues, in conjunction with compliance analyst/auditors as appropriate. In discharge of these duties, will have unimpeded access to all employees and elements of the organization, including the Board of Directors/Trustees and the executive management team. Serves as Privacy Officer for the organization, supporting and overseeing the system-wide privacy issues and a privacy program. Oversees and monitors the implementation of all EHS entities’ compliance activities, programs, policies and procedures, to ensure system integrity and compliance with applicable federal and state laws and regulations. Works diligently to foster a culture and climate of sensitivity to compliant and ethical behavior within the organization. Identifies the appropriate resources necessary to manage the Compliance department and programs, and establishes a budget to support same. Provides a leadership role in and direction to the Compliance Committee, assuring organization-wide program growth and development to meet the evolving regulatory and operational environment, and ensuring thorough, current and effective policies and procedure review, education, and Board education and engagement. In concert with the team of compliance analyst/auditors, ensures that risk assessments are performed at least annually, with compliance work plans created and effectively implemented. Regularly reviews, revises and improves compliance work plans, and implements and modifies any necessary changes on an ongoing basis to improve the prevention, detection and remediation of any compliance issues. Regularly reviews the Corporate Compliance Program policies and manuals and recommends appropriate revisions and modifications. Develops, prepares and implements policies and procedures that establish standards for compliance, providing specific guidance to management, medical staff, and individual departments as appropriate, under the guidance of the Compliance Committee. Responsible for abiding by, upholding and enforcing Elliot Health System’s Code of Conduct to all employees and agents of EHS. This involves working with department directors and managers to assure that employees’ performance evaluations include an adequate assessment of each employee’s knowledge and compliance with the Code of Conduct. Responsible for maintaining a confidential/anonymous reporting system, including a telephone help line, to allow reporting of suspected noncompliance or incidents of fraud and abuse, and adopting procedures to protect anonymity and protect complainants from retaliation. Responsible for maintaining a mechanism for the timely review of complaints, concerns or questions relative to compliance issues, and provides consultative support to all EHS entities as appropriate. Coordinates personnel issues with the hospital’s human resources office when identified during compliance activities. Maintains a record of all reports of suspected compliance issues, or fraud and abuse. Develops mechanisms for communicating changes in applicable laws and regulations or changes in the Code of Conduct to affected individuals. Works with appropriate department directors and managers to develop mechanisms for preventing, detecting and remediating compliance issues. Oversees the development and implementation of compliance training, education and other preventative mechanisms for reducing the risk of noncompliance or fraud and abuse, to all EHS employees, Board members and medical staff. Monitors records of participation in compliance training and education programs. Responsible for ensuring that new hires receive compliance training at orientation. Oversees the development and implementation of monitoring, auditing and other detection mechanisms for identifying occurrences of noncompliance or fraud and abuse. Assists the hospital’s financial and revenue cycle management in coordinating internal compliance review and monitoring activities. Reviews reports of all internal audits and investigates any identified areas of noncompliance revealed in those audits. Works with Elliot Health System’s legal counsel to retain and oversee periodic external auditing, when appropriate. Works with Finance Department (and counsel when appropriate) to assure repayment of billing errors according to EHS policy. When advisable, secures opinions of outside consultants and legal counsel regarding business conduct issues in conjunction with Compliance Committee. Works with Human Resources Department to ensure that the organization has not employed or contracted with any Office of Inspector General (OIG) or General Services Administration (GSA) sanctioned individuals. Provides periodic reports to the Board of Directors regarding the status of compliance activities, and as requested. In addition, may make interim reports to the Board, at the direction of the Compliance Committee. Responsible for maintaining EHS policy database. Responsible for maintaining, updating as appropriate, educating and monitoring record retention policy and schedule compliance. Responsible for coordinating Health Information Portability and Accountability Act (HIPAA) and other privacy concerns, issues or reported violations, and any required inquiries and documentation. Develops, maintains, and delivers privacy-related policies and training. Coordinates with system-wide resources to ensure effective privacy programs and practices. Provides subject matter expertise regarding privacy issues and leads privacy investigations. When appointed by the organization, serves as Compliance Officer for any Accountable Care Organization (ACO) or other entity in which Elliot Health System participates and for which a compliance function is required, carrying out the duties of such appointment as directed.
Qualification and Experience
Qualifications: Master’s Degree from an accredited college or university or JD Degree preferred. 3+ years of experience in the health care/health system setting with progressive compliance and auditing, HIPAA and acute healthcare Joint Commission compliance experience required. Certification in Healthcare Compliance and/or JD preferred. Strong PC skills (e.g., MS Word, Excel, PowerPoint, Project, Visio) required. Strong communication, analytical, research, investigational and interpersonal skills. Knowledge of applicable federal and state laws and regulations related to compliance and privacy issues, including fraud and abuse. This includes timely and detailed analysis of guidance issued by and activities of the Office of Inspector General (OIG), Centers of Medicare and Medicaid Services (CMS), and other governmental agencies. This also includes remaining current and conversant regarding changes that may affect compliance and privacy issues pertaining to healthcare systems, through personal initiative, attendance at seminars and training programs, and professional peer contact and networking. Knowledge of specific laws and regulations, and regulatory, investigative and enforcement activities applicable to health care systems. Ability to manage a diverse, dynamic and demanding workload. Sophisticated understanding of the health care and hospital environment, as well as reimbursement systems, risk management, legal and performance improvement issues and activities pertaining to health care.