Under the general
supervision of the Vice President Corporate Compliance is directly
responsible for the operations of various portions of the Compliance Program
and directly executes sections of the Lifespan Compliance Plan. Directs the staff
executing Lifespan�s Privacy Program who monitor employee access to protected
health information maintain HIPAA Privacy log perform security breach
analysis and make required reports to federal agencies. Directs staff maintaining enhancing and
trending on results of the Compliance Program employee reporting line (Response
Line) and develops Compliance Program policies.
Responsible for the execution of the annual conflict of interest survey
process and responses to physician and staff questions regarding conflicts and
consulting opportunities. Directs and performs special investigations as
requested and in compliance with Lifespan policies and federal and state
regulations. Facilitates and directs compliance
and privacy training to employee and physician staff. Directs the implementation
of compliance operation enhancements such as management of the physician
contract database to ensure compliance with Stark and Anti-Kickback regulations.
Prepares a written summary of work often under Attorney Client Privilege where
problems are found and makes recommendations to correct.
Responsible for directing and maintaining Lifespan�s Privacy
Program by ensuring that sufficient procedural guidance and training has been
developed; relevant policies created employees are following these policies
and receiving required training etc.
Provides Privacy training as required reviews and updates Privacy
Training ensures employees are completing such training etc. Performs breach analysis and federally
Directs staff maintaining the Compliance Program
confidential employee reporting telephone line by responding to questions
regarding Compliance Policy or Regulatory interpretation or performing
resulting follow-up investigations on substantive �hot line� complaints. Oversees the enhancement of the �hot line�
and subsequent reporting trending results on a monthly quarterly and annual
Assists the Vice President Corporate Compliance and
Internal Audit in the preparation meeting presentations and follow up actions
for the Audit & Compliance Committee and the Executive Corporate Compliance
Supervises staff to organize conduct privacy investigations
and audits to ensure compliance with Lifespan policies and federal and state rules.
In consultation with the Vice President Corporate Compliance and Internal
Audit Office of General Counsel; and often Lifespan Senior Management develops
investigatory work steps or audit program guidelines and objectives.
Oversees the audit working papers such as compliance
questionnaires so that sufficient competent and evidential matter is obtained.
Where applicable maintains workpapers to protect Attorney Client Privilege.
Prepares written reports with and for the Vice President
Corporate Compliance of factual findings and recommendations. (Level and quality of report and
recommendations would normally require minimal revision).
Cooperates with regulatory third party external auditors
and consultants. Review results of test
checks and other findings to identify further examination. Collaborate as needed to discuss findings of
Routinely acquires information on changes to various
third-party standards including Medicare and Medicaid participating in
development of internal procedures to respond to same. Assess operational compliance to procedures
in various affiliate departments or units to maximize accuracy and completeness
of charges and codes submitted for payment and to minimize other risks.
Actively participates in the annual Compliance Risk
Assessment by providing feedback and suggestions for potential areas of risk to
review. Audit and monitor.
Directs review of the physician contract database to ensure
compliance with federal regulations such as Stark and Anti-Kickback.
Acts as the Affiliate Privacy Officer for Lifespan Corporate
Services and participates in all such privacy activities including a monthly
privacy log for review.
Coordinates and oversees the collection of the monthly
review of the privacy logs from the Affiliate Privacy Officers at each
Facilitates and chairs the quarterly Affiliate Privacy
Officer meeting including agenda preparation follow up and associated
Responsible for scheduling and monitoring work assignments
and reprioritizing as necessary to maximize productivity. Orients new staff provide ongoing review of
work to ensure accuracy and consistency of methodologies and serve as a
Responsible for assisting in the implementation of
compliance operations enhancements such as the implementation of the electronic
compliance software modules when needed.
Executes various portions of the Lifespan Compliance Plan
designed to measure the risk of non-compliance demonstrate the effectiveness
of the Program or enhance the level of system-wide compliance.
Assists the Vice President Corporate Compliance and
Internal Audit and Office of General Counsel by performing investigations
arising from complaints received via the hot line or because of federal or