Director, Compliance and Privacy

Location: Burlington, MA
Job ID: 163783-1A
Date Posted: Oct 2, 2020
Category: Consultant

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Job Description

Welcome To

Welcome to Beth Israel Lahey Health. We are a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,000 physicians and 35,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.  

About the Job

Reporting directly to the Associate Deputy Compliance Officer for Beth Israel Lahey Health System, the Academic Medical Center (AMC) Compliance Officer is responsible for leading the Compliance Programs for Lahey Hospital and Medical Center (LHMC), its affiliated clinics and outpatient departments, and legacy Lahey Shared Services (LHSS).  The AMC Compliance Officer supervises and mentors assigned entity compliance staff to ensure effective oversight and management of compliance operations, and is a strategic partner in developing and maintaining best in class compliance programs throughout the organization.   

The AMC Compliance Officer is a role model and experienced leader, who works closely with hospital and LHSS senior leadership, leading the compliance activities of the organizations and communicating and collaborating effectively among staff of all levels and backgrounds to establish a culture of compliance.  The AMC Compliance Officer supervises and mentors assigned compliance staff  to accomplish program objectives, facilitate remediation and drive outcomes. The AMC Compliance Officer proactively assesses compliance risks for the organizations in conjunction with leadership and strives to develop risk mitigation strategies that support business operations with minimal disruption.  This leader oversees training, investigations, monitoring, metric reporting, applicable board content, and recommendations for program development, and is responsible for achieving and sustaining effective compliance, ethics and integrity and privacy programs consistent with BILH Compliance goals.

In addition, the AMC Compliance Officer will be a part of the BILH Compliance leadership team and support BILH system initiatives, cross-functional coverage of issues and inquiries as needed, and participate as an effective team member and leader on various system-related projects. The AMC Compliance Officer has extensive experience in healthcare compliance matters and regulatory requirements such as Privacy and Security, Conflict of Interest, Fraud, Waste and Abuse, and other compliance and privacy related matters. As a leader, this individual will provide a high degree of relevant expertise, consultation and guidance to compliance colleagues, entity leadership and operational constituents to ensure compliance with federal, state and local government regulations. The AMC Compliance Officer demonstrates integrity in all aspects of their role and is an ambassador for promoting a culture of compliance throughout the BILH system. 

Essential Duties & Responsibilities include but are not limited to:

The AMC Compliance Officer further develops, designs and maintains the compliance program for the assigned entities and organizations consistent with BILH Compliance Program initiatives.  This includes promoting a culture of compliance, and developing practices designed to ensure adherence to applicable federal, state and local rules and regulations, and hospital or site specific policies within the scope of regulatory compliance and privacy. 

 

Essential Duties and Responsibilities include:

  • Works directly with BILH Compliance Leadership, including the Associate Deputy Compliance Officer and his or her designee(s) to develop and maintain a compliance program designed to ensure compliance with applicable privacy standards and regulations such as HIPAA, HITECH, and various state laws; applicable government payor requirements such as Medicare and MassHealth; and other essential state and federal laws, rules and regulations.
  • Plans, executes, and manages investigations, engaging other BILH Compliance subject matter experts and consulting with legal counsel as needed to effectively manage timely and thorough reviews; maintaining appropriate documentation, providing periodic updates to leadership, appraising stakeholders of potential risk, and invoking escalation protocols as appropriate.  Develops corrective actions together with operations and other leaders, monitors implementation and provides periodic status updates and recommendations as needed.
  • Works closely with the Associate Deputy Compliance Officer and the compliance leadership team, Legal Services and other stakeholders to identify and mitigate risk and potential areas of non-compliance, actively participates in annual risk assessment and other related initiatives.
  • Leads the Compliance and Privacy Program for the AMC and other assigned entities, including establishing effective working relationships with entity leadership; chairing the AMC Compliance Committee; ensuring effective meetings, and participating in board (or delegated) oversight reporting.
  • Responsible for effective program administration, and ensuring that compliance programs are designed in a manner consistent with the Office of Inspector General’s guidelines and other published materials concerning effective compliance programs, as well as BILH compliance objectives.
  • Oversees effective tracking of reports, timely follow-up and investigation.
  • Contributes to various BILH Compliance Operations initiatives such as annual and new hire compliance training and/or other compliance integration efforts. 
  • Stays informed of new and emerging areas of compliance and privacy risks, trends and/or best practices relevant to the compliance and privacy program; shares information with other Compliance Department members and organizational staff as appropriate.
  • Responsible for requests from BILH Compliance Leadership which may include board report preparation, review and investigation of select topics, audit requests, periodic surveys, serving on ad hoc committees, assisting with the annual Work Plan, education and training and other initiatives, etc.
  • Appropriately and effectively engages assigned staff to achieve efficient and effective outcomes. Mentors and guides developing staff as part of project oversight.  Imparts knowledge and best practices to aid staff development, cross-coverage and business continuity.
  • Develops vision and strategy for the compliance programs for the assigned entities and  service lines, consistent with system-wide compliance objectives and serves as a member of the BILH compliance leadership team.

Education:

  • Bachelor’s degree in a related field (health care, business and law); Master’s or other advanced degree preferred

Licensure, Certification & Registration:

  • Professional license (e.g., Nursing, Law), as well as other professional compliance designation such as CHC, CIPP, etc.

Experience:

 

  • Seven to ten years of healthcare compliance and privacy related experience required, along with previous management experience.
  • Five plus years of escalating responsibility and work-experience in the compliance and privacy field (healthcare, law, internal audit) including progressive program and project management roles in large and complex organizations.
  • Previous compliance leadership role as hospital compliance officer

Skills, Knowledge & Abilities:

  • Extensive knowledge of pertinent compliance and privacy regulatory requirements and compliance program elements including OIG Compliance Guidelines, billing compliance principles, COI, OCR guidance and emerging  HIPAA Privacy and Security requirements (among others) in a hospital setting and/or other setting relevant to service line assignments.
  • Demonstrated history of business process expertise coupled with compliance risk management perspective for effective and compliant business recommendations
  • Ability to communicate, collaborate and work effectively with senior leadership, as well as all levels of an organization including management, leadership, and line staff across range of functional areas
  • Demonstrated high ethics and integrity

Preferred Qualifications & Skills:

  • Prior health care compliance and privacy experience in similar setting
  • Excellent research skills, verbal, and written communication skills

Dept/Unit Specific Skills: 

  • Adept at Excel spreadsheet development and maintenance, EPIC EHR, Microsoft Office, G Suite and other compliance systems such as Navex, RL Solutions, ComplyTrack, COISmart, etc

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.