System Deputy Compliance & Privacy Off
• This Executive Director level position reports directly to the Chief Compliance Officer (CCO) for Steward Health Care System (Steward) with indirect reporting to the President of Steward Medical Group (SMG). The System Deputy, SMG Compliance & Privacy Officer needs to be a person of high integrity, and any other duties assigned should not be in conflict with Steward’s compliance program goals and objectives. This position will be based in Dallas, TX and may require some travel to Steward locations as needed.
• Regional Compliance & Privacy Officers (Directors) across the nation report directly to the Divisional System Deputy, Compliance & Privacy Officers, and indirectly to the System Deputy, SMG, Compliance & Privacy Officer
• This position ensures coordination and project management of Steward’s Office of Corporate Compliance & Privacy (OCCP) initiatives for SMG
• The role involves strong collaboration with Steward Medical Group leadership and management teams.
• This position is responsible for driving implementation of Steward’s Compliance & Privacy Program for all provider entities owned by SMG; as well as leading compliance program activities for newly acquired or newly created SMG provider entities
• This position is responsible for driving compliance program “operational excellence” (i.e., standardization, scalability, effectiveness and efficiency) for SMG. Furthermore, this position will assist SMG to meet an evolving landscape of regulatory compliance requirements impacting the SMG owned entities
• Participates as a member of OCCP’s leadership team in a way that furthers the vision, mission and values of Steward including developing effective working relationships with team members and key stakeholders, such as Practice Leadership, and demonstrating value beyond compliance
• Assists the CCO and Divisional System Deputy, Compliance & Privacy Officers with priority investigations, remediation and tracking follow up to any identified corrective action plans
• Under the direction of the CCO, leads compliance program due diligence and integration activities for newly acquired entities including compliance program coverage for newly created SMG owned entities
• Collaborates with OCCP leadership team and other functions (e.g., Internal Audit, Human Resources, Clinical, Revenue Cycle, Information Services, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Under the direction of the CCO, consults with Office of General Counsel (OGC) as needed to resolve legal compliance issues.
• Participates on Steward Medical Group’s Policy Committee and serves as the Compliance and Privacy subject matter expert for the Committee
• Assists SMG Leadership in preparation of meeting materials and agenda for the Divisional SMG Compliance Committee meetings
• Prepares the SMG OCCP Quarterly Activity Report and assists with development of the SMG content for the annual report for the CCO
• Generates and provides the SMG Senior Leadership Team / OCCP Summary Reports, after review with Divisional System Deputies
• Works with SMG Leadership related follow through and corrective actions from the OCCP Revenue Integrity Audits
• Reviews all SMG Conflict of Interest Disclosure Survey’s and works with SMG Leadership on any needed COI Management Plans
• Monitors compliance activities and investigations for SMG nationally to identify trends
• Works closely with the VP, Compliance & Privacy Operations on development of the SMG Monthly Compliance Privacy Program Awareness Activities, presenting to Practice Leadership each month
• Assists the OCCP team with preparation of the annual provider OCCP Work Plan
• Participates in health care compliance and privacy professional organizations to stay abreast of privacy and corporate compliance developments and leading industry practices
• As requested, actively participates in Steward system-wide initiative committees
• Keeps the CCO and Divisional System Deputy, Compliance & Privacy Officers informed of issues on a timely basis
• Ensures collaboration with SMG Leadership and Practice Management to keep them current on the latest compliance program related risks and leading practices
• Under the direction of the CCO, ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required
• Assists SMG management in ensuring consistent application of sanctions for failure to comply with compliance and privacy policies for all members of the workforce, in cooperation with Human Resources and the Office of General Counsel, as applicable.
• Cooperates with the regulators (e.g., CMS, OIG, OCR, State Attorney General, etc) and other parties, as appropriate, in any privacy or compliance audits and investigations
• Implements, monitors and reports on SMG compliance program metrics regarding effectiveness and efficiency to the CCO and work closely with OCCP’s leadership team to take steps to improve performance
• Maintains time and effort reporting records as requested
• Demonstrates 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
• Performs other duties as assigned
REQUIRED KNOWLEDGE & SKILLS
• Knowledge and experience with physician practice management required
• Working knowledge and advanced experience with all general health care compliance and privacy regulations, including interpretation and application required
• Familiarity with operational, financial and information technology security regulations
• Strong oral/written communication and presentation skills a must
• Strong organizational, interpersonal and analytical skills and the ability to function effectively in a fast-paced environment
• Ability to remain composed and even-tempered
• Ability to prioritize and plan work independently
• Ability to interact with all levels of management
• Effectively work with and coordinate the activities of external consultants and legal counsel
• Ability to anticipate potential issues and proactively respond
• Sound business judgment and advanced problem solving skills
• Ability to maintain confidentiality
EDUCATION & EXPERIENCE
Education: A bachelor’s degree required; master’s degree desired.
Experience: A minimum of 5 years experience in compliance and privacy for the physician practice groups, with demonstrated success and evidence of progressive responsibility & leadership. Advanced compliance and privacy, project management and program oversight experience.
Certification/Licensure: Certification in Healthcare Compliance required. Certification in Privacy preferred
Software/Hardware: Microsoft Outlook, Word, Excel, Powerpoint and Internet skills required.
Other: Travel Requirements: Ability to travel regionally and nationally. Must have a valid driver’s license and provide own transportation and be able to travel to Steward locations using a variety of modes of transportation.