JOB SUMMARY

The Chief Compliance Officer (CCO) is responsible for the direct planning and oversight of operational activities in the Enterprise’s new Compliance department, embedded within Administration. This position is responsible for developing and implementing an effective. Enterprise Compliance program to mitigate risks, prevent illegal, unethical, or improper conduct, to promote Enterprise integrity and enhance Enterprise readiness for regulatory, insurance and accreditation audits and site visits. Reporting to the SVP of Enterprise Integrity, the CCO works collaboratively with SVP/General Counsel, and acts as staff liaison to the Audit and Executive Committees of the Boards of Directors. The CCO consults directly with and provides strategic guidance to the Executive Management team by monitoring and reporting results of compliance activities, assessments, and ethics performance of the organization and recommending risk mitigation strategies.

ESSENTIAL JOB DUTIES 

• Directs and oversees the planning, development, coordination and implementation of all functions of Compliance activities actress the Enterprise inclusive of developing an annual Enterprise Compliance Strategic Plan and Work Plan with milestones, a RACI chart, budget, etc. 
• Establishes standards and implements procedures to ensure that the Compliance program is effective and efficient in identifying, preventing, detecting, and correcting noncompliance with applicable laws and regulations
• Ensures that the Enterprise’s policies and procedures are well understood and respected by all employees, and that the Enterprise is complying with all regulatory requirements
• Develops policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation
• Develops the accountability paradigm and PACE card metrics for the Compliance department and its staff (if any) for regular reporting to the Executive Management team and the appropriate committees of the Boards of Directors
• Recommends effective risk management strategies based on internal and external audit and assessment outcomes and industry trends 
• Coordinates internal compliance review and monitoring activities, including periodic reviews of departments
• Interacts with regulators on compliance issues
• Coordinates efforts related to audits, site reviews, and examinations
• Independently investigates and acts on matters related to compliance
• Monitors external review processes
• Investigates possible incidents implicating the inappropriate use or disclosure of Protected Health Information and Patient Privacy, ensuring timely and accurate remediation of any such inappropriate use or disclosure and timely reporting to the Department of Civil Rights, if necessary and serving as an information privacy consultant to the organization 
• Works closely with the insurance brokers of record to minimize risk in the arenas of medical malpractice, billing, privacy of protected health information, premises liability, etc. 
• Collaborates closely with all departments across the Enterprise to assist in the review of applicable laws, rules and regulations, ensuring that appropriate departmental policies and procedures are in place and followed by all to minimize risk, ensure compliance and enhance Enterprise Integrity
• Acts as an independent review and evaluation body to ensure that compliance issues, concerns, or violations within the organization are being/have been appropriately evaluated, investigated, and resolved and promotes continuous organizational learning
• Collaborates closely with the AVP of Quality Improvement and Assurance in monitoring and reviewing organizational Safe Reports to ensure that any actual or potential Serious Safety Events have been appropriately and timely addressed to minimize risk and ensure organizational learning 
• Collaborates with counterparts in clinical and educational departments who lead their respective compliance with accreditation standards (such as ACGME and HRSA)
• Reviews the practices, policies and procedures across operations of the Enterprise and evaluates them for risk and compliance with applicable laws, rules and regulations
• Conducts internal assessments to verify the accuracy of internal records and evaluate them for risk of mismanagement, fraud, waste and abuse
• Is the subject matter expert on compliance and the new Compliance Program and creates, develops, and conducts educational sessions and presentations for staff and the governing Boards on the Compliance Program
• Defines the necessary level of knowledge on existing and emerging regulatory compliance requirements across the Enterprise
• Other duties as assigned