Director Compliance and Privacy
At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.
We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.
In support of this, we commit ourselves to the following values:
If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.
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.
• Drives consistent application of Steward’s Code of Conduct and compliance policies to Good Samaritan Medical Center.
• Acts as a consultative resource to Good Samaritan Medical Center’s 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 Good Samaritan Medical Center’s entity-level 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 Good Samaritan Medical Center’s workforce are knowledgeable of applicable laws, Steward’s Code of Conduct, and Steward’s compliance policies
• 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.
• Manages and supervises the corrective action process including communication, education, involvement in policy/process updates, as well as overall project management
• 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
• Works collaboratively with appropriate Good Samaritan Medical Center workforce members to resolve all compliance issues identified
• 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
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
Education: 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 is a plus
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
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