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The Exec Director of Compliance, Chief Compliance Officer (CCO), is responsible for developing, implementing, overseeing, and improving an effective system-wide compliance program. The CCO designs and manages Elliot Health System’s (EHS) 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 analysts/auditors as appropriate. In discharge of these duties, the CCO will have unimpeded access to all employees and elements of the organization, including the Board of Directors/Trustees and the executive management team. The CCO also serves as Privacy Officer for the organization, providing strategic oversight of the enterprise privacy program, privacy risk management activities, regulatory compliance, breach response, and privacy education initiatives.

• Oversees and monitors implementation of compliance activities, programs, policies and procedures across all EHS entities to ensure compliance with applicable federal and state laws, regulations, and organizational standards.

• Fosters and promotes a culture of compliance, integrity, accountability, and ethical conduct throughout EHS.

• 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, ensuring 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.

• Provides leadership, direction, oversight, and performance management for Compliance Department staff, including establishing priorities, assigning responsibilities, supporting professional development, and ensuring the effective execution of departmental goals, compliance work plans, investigations, auditing activities and privacy functions.

• In concert with the team of compliance staff and operational managers, 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.

• Provides oversight of the Institutional Review Board (IRB) Administrator and Human Research Protection Program.

• Regularly reviews the 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 ensure that employees’ performance evaluations include an adequate assessment of each employee’s knowledge and compliance with the Code of Conduct.

• Oversees the implementation and administration of the EHS Conflict of Interest Policy, including the development, distribution, collection, review, and follow-up of annual conflict of interest disclosures and attestations for members of the Board of Directors, senior leadership, physicians, and other designated individuals; ensures identified conflicts are appropriately evaluated, documented, managed, and reported.

• 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 matters with Human Resources 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. Collaborates with system financial and revenue cycle leadership in coordinating compliance review, monitoring, auditing, and remediation 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 ensure repayment of billing errors according to EHS policy.

• Engages outside consultants, auditors and legal counsel, as appropriate, to support compliance, privacy, regulatory and investigative matters.

• 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 regular and ad hoc reports to the Board of Directors and applicable Board Committees regarding compliance risks, program effectiveness, significant investigations, regulatory developments and corrective action initiatives.

• 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 Insurance Portability and Accountability Act (HIPAA) compliance activities, privacy concerns, investigations, breach response, regulatory reporting and related documentation.

• Oversees enterprise privacy governance practices, including privacy risk assessments, investigations, mitigation plans, workforce education, and collaboration with Information Security and Legal departments.

• 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.

• Provides a leadership role in and direction to the Compliance Committee

• Provides leadership, direction, oversight, and performance management for Compliance Department staff

• 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

• Oversees the development and implementation of monitoring, auditing and other detection mechanisms for identifying occurrences of noncompliance or fraud and abuse. Collaborates with system financial and revenue cycle leadership in coordinating compliance review, monitoring, auditing, and remediation activities

• Oversees enterprise privacy governance practices

• 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

Education: Bachelor's Degree required. Master's Degree or Juris Doctor (JD) from an accredited institution preferred.

Licensure/Certification: Certification in Healthcare Compliance (CHC), Healthcare Privacy Compliance (CHPC), or related compliance certification strongly preferred.

Experience: Minimum seven (7) to ten (10) years of progressively responsible healthcare compliance experience, including leadership responsibility for enterprise compliance programs, investigations, auditing, risk assessments, and board-level reporting. Proficiency with Microsoft 365 applications and compliance, governance, risk management, reporting, and document management systems

Knowledge: 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 for 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.

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.