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This position provides leadership and direction for Compliance and Privacy within the CHRISTUS Santa Rosa region. The incumbent, in collaboration with System and Regional Leadership, is responsible for supporting a culture consistent with the CHRISTUS Mission, Core Values and Code of Ethics by planning, designing, implementing and maintaining the CHRISTUS Santa Rosa system-wide compliance programs, policies, and procedures. This position will lead initiatives in order to foster a culture where ethical and compliant behavior is practiced. This position will develop, implement and maintain adequate internal controls in order to ensure CHRISTUS Santa Rosa will maintain compliance with all applicable laws, standards, and regulatory requirements.
As Compliance and Privacy Director, this position will serve as a role model along with all other CHRISTUS LEADERS for behavior consistent with the Mission, Vision, and Core Values of CHRISTUS Health. He/she will provide direct support to the CHRISTUS Santa Rosa regional Board.
The incumbent will also serve as a member of the regional leadership team and will provide direction and independent review of strategic and business initiatives to ensure conflicts of interest are minimized and regulatory compliance is followed.
Additionally, this person will serve as the Regional Privacy Director. This role is responsible for assistance with policy development and implementation of processes and programs covering the privacy of, and access to, patient health information in compliance with federal and state laws.
CHRISTUS COMPETENCIES FOR MANAGERS AND DIRECTORS
Drives results- Consistently achieving results, even under tough circumstances.
Manages conflict- Handling conflict situations effectively, with a minimum of noise.
Communicates effectively- Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
Directs work- Providing direction, delegating, and removing obstacles to get work done.
Builds effective teams- Building strong-identity teams that apply their diverse skills and perspectives to achieve common goals.
Business insight- Applying knowledge of business and the marketplace to advance the organization’s goals.
Ensures accountability- Holding self and others accountable to meet commitments.
Duties related to Governance / Leadership:
· Provide effective leadership and advice to Regional Leadership on matters of compliance and ethical business practices. Foster open lines of communication and exercise authority to apprise Regional Leadership of any issues of concern relating to compliance activities and procedures
· Provide updates to the Board Committee in the Santa Rosa Region
· Execute the annual compliance work plan and report conclusions and recommendations to Regional Leadership, as appropriate. Participate in the proactive annual risk assessment
· Chair the regional compliance committee, which should generally be held quarterly, unless otherwise approved by the Vice President and Chief Compliance and Privacy Officer. Serve as a Regional authority on compliance related matters, keeping abreast of current changes that may affect the health care systems through personal initiative, seminars, training programs, and peer contact
· Exercise due diligence in concert with Regional Leadership to prevent and detect misconduct and wrongdoing. Undertake all reasonable steps to respond appropriately when an offense is detected and prevent future similar offenses through root cause analysis and trending to prevent isolated incidents from becoming broader, more, wide-spread issues. We must look to prior misconduct to prevent future misconduct and identify patterns that should be addressed. Ensure the enforcement of compliance program standards Foster collaborative relationships with all members of Regional Leadership and Corporate Compliance Committee, as appropriate
· Prepare and present formal written and oral presentations to the Vice President and Chief Compliance and Privacy Officer, Santa Rosa Regional Leadership, and the Board Committee, as appropriate and as called upon to do so
· Provide subject matter expertise and guidance to the Senior Leadership by reviewing and providing input on potential conflicts in strategy and business development initiatives
· Perform other duties as assigned by the Vice President and Chief Compliance and Privacy Officer or his assigns
Duties related to Ethical Business Practices:
· Ensure that reporting systems provide timely and relevant information on all aspects of compliance issues
· Develop and monitor efficient processes and procedures that continue to support an effective compliance program
· Provide subject matter expertise on the resolution of Integrity Line issues in a manner that ensures a confidential and easily accessible system for Associates to report alleged violations of standards without fear of retribution
· Provide guidance to leadership, medical staff and individual departments so that clinical, research and administrative managers are aware of their responsibility for ensuring compliance for their areas
Duties related to Compliance:
· Maintain and implement a comprehensive region-wide compliance program which ensures compliance with federal and state billing regulations and the Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) Compliance Program Guidance
· Implement processes, procedures, and structures to maintain a current, active and effective Compliance Program
· Collaborate with key management Associates, key departments and committees and the Corporate Compliance Team, as necessary, to ensure compliance with applicable laws and regulations and be consistent with the CHRISTUS Health Corporate Compliance Program
· Collaborate with the Legal Team, the Vice President and Chief Compliance and Privacy Officer and Corporate Compliance Team to ensure proper reporting of violations to enforcement agencies as appropriate or required, as directed by the Vice President and Chief Compliance and Privacy Officer
· Ensure processes and procedures are in place to maintain consistency of the Compliance Program within the overall CHRISTUS Health direction to include consistent application of sanctions for failure to comply with compliance policies and procedures for all individuals in the region’s workforce, extended workforce and for all business associates, in cooperation with Human Resources and Administration Teams, as applicable
· Manage integrity line reporting and ensure issues are closed timely
· Ensure work plan activities are completed monthly and that any associated Corrective Action Plans (CAP’s) are implemented, tracked, and closed timely
· Present work plan activities in conjunction with the compliance auditor to the regional compliance committee and the Corporate Compliance Team
· Act as an independent review and evaluation body to ensure that compliance issues and concerns within the organization are being appropriately evaluated, investigated, and resolved
· Lead non-compliant issue resolution activities and corrective action. Any non-compliant issue will be coordinated through the Corporate Compliance Team for resolution
· Responsible for establishing guidelines for collecting and storing correspondence from regulatory and licensing agencies across the region, as appropriate, for future reference. Provide a copy of all correspondence to the Corporate Compliance Team
· Collaborate with applicable Departmental Directors/Managers during visits from regulatory agencies to assist in the collection of information and ensure complete and accurate documentation of the proceedings and then report all things back to the Corporate Compliance Team
· Ensure the accurate completion and timely submission of reports requested by the Corporate Compliance Team
· Periodically review the Code of Ethics and Business Conduct and collaborate with the Human Resources Team to provide Code of Ethics and Business Conduct education, as well as new Associate orientation sessions. Ensure knowledge and region-wide distribution of the Code
· Ensure physician leader completion of annual conflict of interest
· Review physician agreements as directed by the Corporate Compliance Team
· Plan and direct periodic meetings with hospital staff to enhance knowledge, address issues, share information to enhance an effective compliance program, and foster the growth of an integrity-based culture
· Ensure the reporting requirements for any Compliance and Settlement Agreements are met
Duties related to Department Management:
· Provide direction and support to direct reports and departments, including performance evaluations, orientation and training. Develop and administer departmental policies and procedures
· Manage direct reports to follow the CHRISTUS Core Values
· Direct and manage other duties as directed by the CHRISTUS Vice President, Chief Compliance and Privacy Officer and Corporate Compliance Team
· Recruit, develop, and manage staff in a manner that builds service capacity and adds value to the overall Compliance Program
· Develop and/or enhance programs for monitoring and improving the quality of services and outcomes provided by the department.
Duties related to Privacy Program:
· Act as the Regional Privacy Director
· Provide leadership support to Privacy Manager and maintain an active and effective HIPAA Program
· Coordinate all Privacy concerns with the Vice President and Chief Compliance and Privacy Officer and the Director of Privacy
· Maintain current knowledge of applicable federal and state privacy laws and accreditation standards, and monitor advancements in information privacy technologies and requirements to ensure organizational adaptation and compliance
Duties related to Other Administrative Responsibilities
· Other duties as reasonable and necessary at the direction of the Vice President and Chief Compliance and Privacy Officer
POSITION SPECIFIC COMPETENCIES
· Ensure work plan activities are completed and submitted by the fifth working day of the month
· Work plan tracking spreadsheet and regulatory correspondence reports are submitted by the fifth working day of the month
· Work plan activities are presented at the Regional Compliance Committee
· Board reports are submitted to system office five days before they are due for review at the Regional level
· Corrective Action Plans are implemented, tracked and closed within 60 days
· Integrity line issues are closed within 30 days, unless exception approved
· From time-to-time, the Vice President and Chief Compliance and Privacy Officer will provide specific guidance and make recommendations for timely submission of reports. Candidate will comply with all such requests to the best of their ability
· Bachelor’s degree required
· Master’s degree in business/health care related field, CPA or JD preferred
· Strong interpersonal skills, including the ability to interact effectively with Medical Staff, Hospital Executives, Regional Board, facility management and Associates, Corporate Associates and the general public
· Ability to make independent decisions as necessary
· Effective skills in team-building, shared decision making and change management
· Ability to be flexible, creative and motivated by challenges
· Ability to initiate, coordinate and follow multiple projects through to completion
· Excellent analytical, written, and oral communication skills
· Experience in public speaking and business presentations
· Excellent spreadsheet, internet, Power Point and word processing skills
· Ability to research and analyze regulations and communicate them to leadership
· Ability to work in a rapidly changing and stressful environment
· Knowledge of hospital operations, departments and procedures, as well as laws, regulations, and guidelines pertaining to healthcare
· Minimum of 5+ years demonstrated experience leading health care regulatory and compliance functions
Licenses, Registrations, or Certifications
· CHC preferred