Job Description

Position Summary

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 community hospitals and Steward Medical Group (SMG) physician practices in a designated region.

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

Key Responsibilities

    • Drives consistent application of Steward’s Code of Conduct and compliance policies across the assigned Steward entities.
    • Establishes and fosters effective working relationships and builds credibility within the Steward hospitals and SMG clinics to support a culture of compliance.
    • Identifies potential risk areas and assists the Steward hospitals/SMG clinics with developing risk mitigation and/or corrective action plan strategies.
    • Acts as a consultative resource to assigned hospital/SMG leadership on issues concerning compliance and privacy matters, and provides recommendations to enhance policies, procedures and internal controls as needed.
    • Ensures that information is provided to assigned hospital-level/SMG management to keep them current on the latest compliance program related risks and leading practices.
    • Works with the OCCP leadership in the development and delivery of compliance and privacy training programs, ensuring all members of the assigned entities’ workforce are knowledgeable of applicable laws, Steward’s Code of Conduct and Steward’s compliance policies.
    • Ensures all identified issues are logged in the OCCP database (ComplyTrack) accurately and timely, and conducts regular documented follow up until issues are resolved. Works 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.
    • Leads investigations or supervises investigations of compliance and privacy concerns at the assigned hospitals/SMG clinics 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.
    • Manages communication, risk assessment and reporting responsibilities as it relates to identified federal and state data breach laws.
    • Reviews conflict of interest disclosure forms for assigned hospitals/SMG clinics to identify any concerns that may need to be brought to the attention of the System Deputy, Compliance & Privacy Officer and hospital/SMG leadership for follow-up or resolution.
    • Participates in health care compliance and privacy professional organizations to stay abreast of privacy and corporate compliance developments and leading industry practices.
    • Attends and/or co-chairs hospital-level Compliance Committee meetings as requested and ensures documentation of meeting is complete and timely.
    • Participates in periodic OCCP team meetings in order to ensure effective communication.
    • As requested, actively participates in Steward’s committees as an OCCP representative.
    • Prepares individual entity and/or regional written activity reports, on a quarterly basis or as requested
    • Keeps the Divisional System Deputy, Compliance and Privacy Officer informed of compliance program activities and issues on a timely basis.
    • Provides updates to assigned Steward hospital/SMG 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.
    • Collaborates 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.
    • Maintains time and effort reporting records as requested.
    • Performs other duties as assigned.

Required Knowledge & Skills

    • Knowledge and experience with all general health care compliance and privacy regulations required.
    • Knowledge and experience with hospital specific health care laws and regulations, and hospital inpatient/outpatient coding and billing compliance required.
    • Familiarity with operational, financial, and information technology security regulations is a must.
    • Effectively work with and coordinate the activities of external consultants and legal counsel.
    • Ability to anticipate potential issues and proactively respond.
    • Good judgment and problem solving skills.
    • Ability to maintain confidentiality.

Education/Experience/License/Technical/Other

    • Education: A bachelor’s degree required.
    • Experience: A minimum of 5 years of 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.
    • 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

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Application Instructions

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