Summary:

The Director Compliance is responsible for directing and implementing the

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Health compliance program in the designated region/ministry. The Director, in collaboration with System and Regional Leadership, is responsible for supporting a culture consistent with the

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Mission, Core Values and Code of Ethics by planning, designing, implementing and maintaining the

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Health Compliance Program in the designated

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Region. The Director is an integral, integrated member of the

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Compliance team. As a key member of the

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Health Compliance and Regional leadership teams, the Director promotes the highest standards of compliance and ethical conduct. The Director is responsible for planning, developing, implementing and coordinating systems to detect, correct and prevent potential issues of noncompliance and assess and mitigate compliance risk within the designated region/ministry. The position requires collaboration with system leadership and periodic travel to various facilities.

Responsibilities:

Meets expectations of the applicable One

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Competencies:

Leader of Self, Leader of Others, or Leader of Leaders. Promotes and executes the

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Compliance Program through consistent application of

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Compliance and Privacy policies and procedures and

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Code of Ethics. Serves as the compliance expert for their supported Region/Ministry. Provides effective leadership, advice, and counsel to Regional Leadership on matters of compliance and ethical business practices. Leads the Regional compliance committee(s) and provides updates to the Regional board(s). Prepares and presents formal written and oral presentations to Regional Leadership and the Board as necessary. Oversees the performance of the designated Regional/Ministry Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness. Addresses new and emerging compliance laws and requirements in collaboration with

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leadership, including the development of education materials and policies and procedures as necessary. Conducts and coordinates compliance investigations into matters including, but not limited to, the Anti-Kickback Statute, Stark Law, Exclusion Statute, EMTALA, Beneficiary Inducement, Antitrust and other State and Federal healthcare laws and regulations. Maintains all investigation notes and files in a contemporaneous, organized manner within the compliance incident reporting database. Ensures individual ministry compliance with the

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Health Compliance Program through consistent application of compliance policies and guidelines. Recommends solutions and corrective actions to remediate identified compliance violations and monitors the successful implementation and sustainability of associated corrective action plans. Coordinates responses to identified compliance questions, concerns, or federal/state inquiries or investigations. Tracks the resolution of corrective actions agreed to by senior leadership in response to compliance audits or investigations and provides summary reports of activity. Conducts risk assessments on a continuous basis to evaluate and mitigate compliance risk. Links risk assessment activity to the development and prioritization of annual Compliance Work Plan. Keeps all assigned Compliance Work Plan activity up to date and identifies and escalates any barriers that may prevent any work from being accomplished as planned. Assists in setting strategy for the annual work plan and addressing high-risk compliance and privacy issues. Works closely with the

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Health legal team and other applicable functional areas to ensure proper interpretation, dissemination and education regarding compliance laws and regulations. Assists with special project preparation and follow-up, as needed, under the direction of the System Director of Compliance and Privacy.

Job Requirements:

Education/Skills Bachelor's degree in business, healthcare, or a related field required. Master's degree preferred. Experience Minimum of 5 years of experience in healthcare, compliance, physician practice operations, ethics, patient privacy, auditing, regulatory affairs, law, or a combination required. Experience leading a compliance program in a large, complex organization. Experience handling complex compliance/privacy investigations. Licenses, Registrations, or Certifications Healthcare Compliance certification (CHC) preferred within first 12 months of hire.

Work Schedule:

8AM - 5

PM Monday-Friday Work Type:

Full Time