This position administers the Logan Health (LH) Compliance Program by implementing systems and processes to promote compliance with applicable laws, regulations, and standards. Ensures the Board of Trustees, leadership, employees and volunteers comply with the laws, regulations, standards, Code of Conduct, and LH system policies and procedures are followed. This position, in collaboration with the Compliance Committee, is authorized to implement all necessary actions to achieve the objectives of an effective compliance program.

Qualifications:

• Bachelor’s degree in a related field of study required; JD, MBA/MHA, PhD or other appropriate advanced degree preferred.

• Certified Compliance and Ethics Professional (CCEP) or Certified in Healthcare Compliance (CHC) required within two (2) years of hire.

• Minimum of five (5) years’ leadership experience required.

• Minimum of seven (7) years’ experience in compliance administration required.

• Possess proficient knowledge of federal and state regulatory law including fraud and abuse laws, Stark, Anti-kickback, HIPAA Privacy and Security, Medicare Conditions of Participation, EMTALA, FDA, and/or OHRP regulations required.

• Proven track-record designing, building, and implementing a system wide compliance program required.

• Promotes excellence through setting high standards and providing high quality outcomes.

• Ability to act with integrity, kindness, and exhibit empathy.

• Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.

• Commitment to working in a team environment and maintaining confidentiality as needed.

• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.

• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

• Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.

Management Job Duties:

Strategic Execution

Drive organizational objectives by operationalizing changes and initiatives effectively and efficiently. Proactively anticipate both the needs of Logan Health and the impact operations has on the organization’s success. Collect and analyze data, prepare and present recommendations, and explain associated benefits and risks for improving operations.

Business Acumen

Demonstrate and further develop competencies in the areas of leadership, financial management, employee engagement, human resources knowledge, organizational dynamics and governance, organizational communication, strategic planning, change management, risk management, compliance, patient safety and quality improvement.  Demonstrate professional ownership, self-development and a desire for life-long learning.

Emotional Intelligence

Serve as a role model for others by exhibiting the Logan Health core values: integrity, compassion, service, excellence and ownership. Lead and influence the team to provide outstanding customer service. Develop and foster relationships with other Logan Health leaders, departments and members of the team to support open communication, trust, transparency and collaboration.

Leadership

Creates a supportive department culture by fostering individual motivation, coaching and training for optimum job performance. Collaborates with Human Resources to develop, implement and support programs and processes that add value to Logan Health, its leadership and employees.  Leads to improve culture, employee and physician engagement, empowerment, growth and retention, while remaining committed to Logan Health’s management and prosperity for its customers, employees and community.

Job Specific Duties:

• Serves as Deputy to the Chief Compliance and Privacy Officer, assisting with Compliance Operational Excellence initiatives as communicated and expected by the Office of Inspector General (OIG) following the closure of the Corporate Integrity Agreement.

• Develops, implements, manages and distributes policies, procedures and practices designed to promote compliance with the requirements set forth in the Office of Inspector General’s Compliance Program Guidance and with federal and state health care program requirements. 

• Maintains Compliance policies in compliance with the federal, international, and state laws and regulations.

• Monitors the compliance activities engaged in by the system. Reports obligations under federal and state health care program requirements.  Collaborates with departments, to integrate compliance into daily healthcare operations.

• Directs the implementation and management of the Compliance Program, required activities, and reports to facilitate compliance with the federal and state health care program requirements.

• Acts as a liaison with the regulatory agencies and seeks guidance on effective steps to meet the intent of federal and state health care program requirements and improve the overall Compliance Program.

• Responds to alleged violations of laws, rules and regulations, policies and procedures, and the Code of Conduct by evaluating and/or recommending the initiation of investigative procedures. Oversees the follow-up on reported concerns for appropriate evaluation, investigation, and resolution. Reports alleged violations to various enforcement agencies, as required.

• Ensures Chief Compliance and Privacy Officer is updated regarding compliance-related matters.  Chairs the relevant Compliance Regulatory Committees.

• Collaborates with leadership to identify potential areas of compliance risks and vulnerabilities. Conducts system-wide risk assessments, develops and implements corrective action plans for the resolution of identified issues.

• Monitors the operation of the Compliance Program and related activities on a continuing basis and takes appropriate steps to improve its effectiveness.

• Updates leadership on changes in compliance requirements, expectations, and regulatory requirements.

• Complies with, and actively promotes, the Standards of Conduct and all other system policies and procedures.

• Develops, coordinates, and participates in routine multifaceted educational and training programs that focus on the requirements of the Compliance Program. Strives to ensure all appropriate stakeholders are knowledgeable of and comply with pertinent federal and state health care program requirements.

• Oversees the Logan Health Compliance Department, including development of budget and supervision of assigned staff.

• Serves as the state and federal liaison in conjunction with legal counsel regarding verbal and written communication to state and federal agencies.

• Establishes compliance dashboard for trends, goals and risks system wide. 

• Establishes standard repeatable work and self-service options system-wide to empower facilities in early and immediate resolution.

• Remains abreast of regulatory trends, participates in continued education and seeks to network with stakeholders in like organizations. 

The above essential functions are representative of major duties of positions in this job classification.  Specific duties and responsibilities may vary based upon departmental needs.  Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job.  Not all of the duties may be assigned to a position.

Shift:

Day Shift - Variable Hours (United States of America)

Logan Health operates 24 hours per day, seven days per week.  Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Notice of Pre-Employment Screening Requirements

If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:

• Criminal background check

• Reference checks

• Drug Screening

• Health and Immunizations Screening

• Physical Demand Review/Screening