Job Description

Location: Steward Health Care
Posted Date: 4/1/2021

POSITION SUMMARY

  • The Regional Compliance & Privacy Officer is a member of the Office of Corporate Compliance and Privacy (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 and the physician practices in a region.
  • This position reports directly to a Divisional System Deputy Compliance & Privacy Officer and indirectly to the Hospital President. The Regional Compliance & Privacy Officer 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 locally in the assigned region and will require some travel among assigned entities.
  • The Regional Compliance & Privacy Officer is responsible for driving implementation of Steward’s Compliance Program at the provider entity level. This position will be accessible to their assigned local entity in order to implement and maintain the Compliance & Privacy Program and to provide guidance to the entity management teams.

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 provider entities to support a culture of compliance
  • Identifies potential risk areas and assists the Steward entities with developing risk mitigation and/or corrective action plan strategies
  • Acts as a consultative resource to assigned entity 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 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 the assigned entity 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 local entity meetings, including Compliance Committee meetings
  • Leads investigations or supervises investigations of compliance and privacy concerns at the assigned entities that are raised through the various reporting 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 entities 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
  • 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 entity-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 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 entity-level management on compliance & privacy program activities and issues on a regular basis (at least quarterly)
  • Facilitates entity 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
  • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment
    • Commits to recognize and respect cultural diversity for all customers (internal and external)
    • 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 all general health care compliance and privacy regulations required
  • Knowledge and experience with hospital and physician practice specific health care laws and regulations, and inpatient/outpatient coding and billing compliance required
  • Familiarity with operational, financial, and information technology security regulations is a must
  • Strong oral/written communication and presentation skills a must
  • Strong leadership, organizational, interpersonal and analytical skills and the ability to function effectively in a fast-paced environment
  • 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
  • Good judgment and problem-solving skills
  • Team player
  • Ability to maintain confidentiality

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER

  • 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 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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