Chief Compliance & Privacy Officer
Healthcare
Wisconsin (on-site role with relocation package available)
Why Join Us
- Business in growth mode with over 14,000 employees and ongoing initiatives to expand both organically and via acquisitions
- Top 15 Health System designation by IBM Watson/Truven
- Named Platinum Well Workplace by the Wellness Council of America (WELCOA) for meeting the highest standards of wellness support for employees
- Opportunity to continue the development of robust and effective compliance and privacy programs in existing business and new entities
- Opportunity to join an impressive executive leadership team focused on collaboration and an existing culture of compliance
Core Responsibilities:
- Reporting to the Board of Directors and the CEO, responsible for the development, implementation, and oversight of an effective Compliance and Privacy program; works collaboratively to achieve system objectives and in areas of planning, implementing, and evaluating compliance programs and strategies in the delivery of integrated health services on a system-wide basis
- Partner with the General Counsel to keep informed on upcoming and ongoing strategies and system objectives
- Regular interaction with medical staff, community leaders, government agencies and legal advisors to carry out the goals and objectives of system-wide compliance program; provides an objective and independent compliance evaluation of various functional processes which may include issues such as Medicare and Medicaid billing, anti-kickback, fraud and abuse, managed care compliance, anti-trust, labor and employee relations, environmental health and safety matters, various trade practices, and specific issues which may arise
- Oversees the development, implementation, maintenance of privacy program; ensures compliance with federal and state privacy laws and work collaboratively with the Chief Information Officer and other leaders on protecting the organization’s information
Compliance Responsibilities:
- Designs, develops, implements and oversees day to day operations of the compliance program ensuring compliance with federal and state regulatory requirements and internal policies and procedures
- Provides input and representation on key compliance initiatives, organizational initiatives, meetings and committees
- Identifies areas of organizational risk and makes recommendations to Senior Leadership around system controls, policies and procedures to assure limited compliance exposures
- Evaluates regulatory requirements and identifies potential operational impacts; advises operational units as required and prepares reports for Senior Leadership; recommends and implements changes to internal company processes as needed
- Maintains a system of management reporting that provides the system with timely and relevant information on all aspects of compliance issues
- Directs efforts to effectively incorporate the compliance program into the organization, including written materials and training programs designed specifically to promote understanding of compliance issues, laws and regulations, and consequences of noncompliance
- Leads Compliance Committee meetings (Compliance Program Executive Committee, Compliance Program Operations Committee, and any appropriate workgroups and sub-committees), develops appropriate agendas, reports, and other information for Compliance Committee meetings
- Directs efforts to develop annual compliance and privacy work plans for the organization
- Directs efforts to ensure effective employee compliance education program for new hires, HIPAA, and annual compliance training
- Works with operations leadership to provide adequate information to ensure they and their employees have the pertinent information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner
- Develops and oversees a system-wide audit function to proactively audit areas of high risk for affiliate organizations.
- Assures lines of communication including establishing and maintaining a Compliance Hotline Reviews complaints, concerns, or questions relative to compliance issues and provides consultative leadership and support to all entities as appropriate
- Oversees and/or monitors compliance investigations and compliance problems, questions, or complaints received internally or from customers/agencies; monitors corrective action plans and recommends appropriate disciplinary action for compliance violations to assure consistency in application of the Code of Conduct Policy
- Monitors effectiveness of compliance programs by analyzing data around compliance training, compliance issues reported and audit findings
- Provides project management of key organizational initiatives with compliance implications such as ICD-10
Privacy Responsibilities:
- Provides development guidance and assists in the identification, implementation, and maintenance of information privacy policies and procedures in coordination with management, committees and legal counsel
- Performs initial and periodic information privacy risk assessments and conducts related ongoing compliance monitoring activities in coordination with the entity’s other compliance and operational assessment functions
- Ensure collaboratively that the organization has and maintains appropriate privacy and confidentiality consent, authorization forms, notices and materials reflecting current organization and legal practices and requirements
- Oversees, directs, delivers / ensures delivery of initial and privacy training and orientation to all employees, volunteers, medical and professional staff, contractors, alliances, business associates, and other appropriate third parties
- Participates in the development, implementation, and ongoing compliance monitoring of all trading partner and business associate agreements, to ensure all privacy concerns, requirements, and responsibilities are addressed
- Establishes a mechanism to track access to protected health information, within the purview of the organization and as required by law and to allow qualified individuals to review or receive a report on such activity
- Works cooperatively with the HIM Director and other applicable organization units in overseeing patient rights to inspect, amend, and restrict access to protected health information when appropriate
- Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization’s privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel Reviews all system-related information security plans throughout the organization to ensure alignment between security and privacy practices and acts as a liaison to the information systems department
- Works with all organization personnel involved with any aspect of release of protected health information, to ensure full coordination and cooperation under the organization’s policies and procedures, and legal requirements
- Maintains current knowledge of applicable federal and state privacy laws and accreditation standards, and monitors advancements in information privacy technologies to ensure organizational adaptation and compliance
Requirements:
- Preferred: Master’s Degree
- Significant experience as a Chief Compliance Officer from a complex multi-location healthcare system
- Significant experience leading a compliance team in a healthcare system • Experience reporting and presenting to Boards and Committees on a regular basis
- Demonstrable experience in utilizing data management and analysis to enhance reporting and presentations for executive team, Board members and committee members
- Demonstrable experience in enhancing compliance and privacy training, education and communication to generate positive employee engagement
