Compliance & Privacy Director #3

Who We Are: St. John's Episcopal Hospital is the only hospital providing emergency and ambulatory care to the densely populated, culturally and economically diverse, and medically underserved populations of the Rockaways and Five Towns in southern Queens County and southwestern Nassau County, New York. Celebrating over 110 years of community care, the 257-bed facility provides people of all faiths with comprehensive preventive, diagnostic treatment and rehabilitative services, regardless of ability to pay. Come Grow With Us! Type: Full-Time (75 hours biweekly) Shift: Days Hours: 8:30 AM - 5:00 PM Salary: $115,000 - $130,000 Job Summary: The Compliance and Privacy Director is responsible for the day-to-day operations of the Compliance Department. This role works closely with the Chief Compliance & Privacy Officer to promote compliance with all applicable federal and state healthcare program laws, regulations, and industry standards. Specifically, the director will develop, implement, and maintain effective compliance and privacy policies and procedures, conduct investigations, perform compliance and privacy integrity audits, and provide training and education for compliance program covered persons. This role requires a robust understanding of compliance and privacy regulations, tactical oversight of compliance initiatives, and effective collaboration with key stakeholders across the organization. Responsibilities: Policy and Procedure Development: Create, review, and update policies and procedures related to compliance and privacy, ensuring they are clear, concise, and in line with applicable laws and regulations. Investigations: Conduct thorough investigations into potential compliance and privacy violations, identifying root causes, and recommending corrective actions. Training and Education: Develop, implement, and review at least annually the organization's Training and Education Plan, as well as deliver compliance and privacy training programs to compliance program covered persons, ensuring they understand their roles and responsibilities in maintaining compliance. Research and Guidance: Coordinate the provision of compliance and privacy research and guidance upon request. Compliance Risk Assessments: Assist the Compliance Committee in conducting annual compliance risk assessments that identify potential risks and develop mitigation strategies. Compliance Committee: Support the quarterly Compliance Committee by coordinating informational and analytical presentations. Metrics and Reporting: Develop and track key performance indicators related to compliance and privacy, providing regular reports to the Chief Compliance Officer and organizational leadership. Regulatory Compliance: Maintain documentation that demonstrates compliance and privacy program effectiveness and coordinates organizational responses to regulatory agency requests, reviews, audits, and investigations. Program Integrity Audits: Conduct compliance and privacy program integrity audits to assess the effectiveness of the program and identify areas for improvement. Compliance Work Plan: At the direction and oversight of the Chief Compliance & Privacy Officer, develop, update, and execute a comprehensive compliance program work plan. Requirements: Minimum of five (5) years of professional experience working in healthcare systems settings (preferably hospitals and/or physician groups) required. Minimum of five (5) years of healthcare compliance program experience required. Robust knowledge of compliance and privacy laws, regulations, and guidelines, including Stark law, Anti-Kickback Statute, HIPAA, EMTALA, and Federal Sentencing Guidelines required. Current Certified in Healthcare Compliance (CHC) and/or Certified in Healthcare Privacy Compliance (CHPC) or Certified Information Privacy Professional (CIPP) required within 12 months of hire date. Undergraduate degree in healthcare administration, public administration, business, law, or a related field required. Master's degree or other advanced degree in healthcare administration, public administration, business, law, or related field preferred. Additional Skills: Experience with governmental regulatory requirements, inspections, and audits, including but not limited to the federal DHHS Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Office for Civil Rights (OCR), as well as the NYS Office of Medicaid Inspector General (OMIG), NYS Department of Health (DOH), and NYS Office of Mental Health required. Maintains current awareness and expertise with changes in healthcare compliance and privacy laws and best practices required. Ability to provide guidance to other departmental staff in identifying and resolving compliance and privacy matters, questions, or concerns required. Excellent written and verbal communication skills required. Strong analytical, attention to detail, and critical problem solving skills required. Ability to build strong relationships with colleagues at all levels of the organization. Strong organizational and time management skills required. Experience with electronic health records (EHRs) and other healthcare information systems required. Ability to work independently and partner with diverse professional teams required. Proficiency with Microsoft Word, PowerPoint, and Excel required. Proficiency with Gmail and Google Calendar, as well as other systems, software, and databases preferred; and Performs other related duties as assigned or requested. EHS maintains the right to add or amend job duties in conformance with applicable legal and regulatory requirements. Experience with governmental regulatory requirements, inspections, and audits, including but not limited to the federal DHHS Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Office for Civil Rights (OCR), as well as the NYS Office of Medicaid Inspector General (OMIG), NYS Department of Health (DOH), and NYS Office of Mental Health required. Maintains current awareness and expertise with changes in healthcare compliance and privacy laws and best practices required. Ability to provide guidance to other departmental staff in identifying and resolving compliance and privacy matters, questions, or concerns required. Excellent written and verbal communication skills required. Strong analytical, attention to detail, and critical problem solving skills required. Ability to build strong relationships with colleagues at all levels of the organization. Strong organizational and time management skills required. Experience with electronic health records (EHRs) and other healthcare information systems required. Ability to work independently and partner with diverse professional teams required. Proficiency with Microsoft Word, PowerPoint, and Excel required. Proficiency with Gmail and Google Calendar, as well as other systems, software, and databases preferred Performs other related duties as assigned or requested. EHS maintains the right to add or amend job duties in conformance with applicable legal and regulatory requirements. Working Conditions: This position requires regular interaction with organizational leadership, physicians, and patients. Occasional travel may be required between the organization's locations for meetings, trainings, professional development, audits, and investigations.

Created: 2024-11-16