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Director Compliance - Sharp Grossmont Hospital

Job ID: 106951 Date posted: December 19, 2020

  • Sharp HealthCare
  • Corporate Compliance
  • Executive Jobs
  • Day Job
  • Full-Time

Responsibilities

Director of Compliance – Sharp Grossmont Hospital (SGH)

Sharp Grossmont Hospital

Sharp Grossmont Hospital is the largest not-for-profit, full-service acute care hospital in the region with 536 beds. The hospital has outstanding programs in heart care, orthopedics, rehabilitation, robotic surgery, mental health, stroke care and women’s health. In addition, the hospital’s Emergency and Critical Care Center is one of the most technologically advanced emergency and intensive care facilities in the nation.

Sharp Grossmont Hospital is nationally recognized as a MAGNET®-designated hospital for patient care and nursing practices. This designation is the “gold standard” for patient care and nursing excellence and is the highest honor awarded by the American Nurses Credentialing Center.

Summary:

The Director of Compliance at Sharp Grossmont Hospital (SGH) reports directly to the Vice President of Corporate Compliance for Sharp HealthCare, with dotted line reporting to the Chief Executive Officer of Sharp Grossmont Hospital. The Director of Compliance is responsible for leading the Compliance and Privacy Program for Sharp Grossmont Hospital, and for ensuring effective oversight and management of compliance operations with an intent of preventing and detecting violations of law and other misconduct and to promote ethical practices and a commitment to compliance with applicable federal, California, and local laws, rules, regulations, and internal policies and procedures.


The Director is an ambassador for the Compliance program and actively promotes an ethical culture through actions and communication.

The Director often serves as the SGH Compliance Officer and is a role model and leader. The role involves assistance with both strategic leadership of Sharp HealthCare (SHC) compliance program and strong collaboration with entity-level management teams. The Director also supports SHC system initiatives including routine and ad hoc reporting for SHC Board purposes, supports coverage of investigations as needed and participates as an active and effective team member and/or leader on compliance or privacy-related initiatives.

Skills and Qualifications:

  • Minimum of five (5) years of healthcare compliance and privacy related experience with escalating responsibility and experience is required.

  • Significant compliance orientation, coupled with business process expertise is needed.

  • Demonstrated knowledge of current compliance thinking and practices is needed.

  • Progressive program and project management roles in large and complex organization is needed.

  • Excellent research and communication skills are necessary.

  • Minimum of two (2) years of experience in acute health care environment in a complex health system is preferred.

Skills, Knowledge and Abilities:

Knowledge of pertinent compliance and privacy regulatory requirements and compliance program elements including demonstrated understanding of OIG Compliance Guidelines, coding and billing compliance principles, fraud waste and abuse (e.g. stark law, anti-kickback standard), CMS Conditions of Participation, and HIPAA and California State Privacy requirements in a hospital setting.

Education:

Bachelor’s degree in healthcare, business or law required.

Certifications and Licensure:

Professional compliance designation such as CHC, CPC, etc, preferred.

Key Responsibilities:

 

Leadership

  • Develop vision and strategy for compliance program for SGH and serves as member of SHC compliance leadership team.

  • Lead the Compliance and Privacy Program for SGH including day-to-day compliance program oversight and administration, ensuring that the program is designed in a manner consistent with the Office of Inspector General’s guidelines and other published materials concerning effective compliance programs

  • Lead SGH compliance and privacy monitoring and auditing activities and coordinate/communicate with SHC Compliance staff.

  • Demonstrate commitment to quality and operational excellence by providing leadership and offering recommendations and solutions through creativity, always seeking continuous improvement, initiating breakthroughs and working to resolve issues/barriers.

  • Effectively makes timely decisions focused on performance and results, focusing on imperatives/projects and processes that are designed to provide the maximum quality/safety/security/integrity for Sharp HealthCare patients, staff, physicians and/or leadership. 

Cooperation and Teamwork

  • Work closely with the System Compliance Officer and his or her designees, entity leadership, operational staff, Legal Services, Internal Audit and other stakeholders to identify and mitigate risk and potential areas of non-compliance, actively participates in annual risk assessment and other related initiatives.

  • Work in cooperation with revenue cycle and entity finance on matters related to the hospital chargemaster, billing and/or charging matters leveraging SHC Compliance team as-needed.

  • Support entity leadership in assessing compliance risk related to new services, new products or new locations.

  • Supports collaboration between risk functions at the entity and has visibility into overall risk posture.

  • Coordinate with various departments, such as Legal, Human Resources, Operations and other departments as required, to develop and deliver appropriate annual compliance training, as well as ongoing training on compliance related topics as needed.

  • Coordinate and/or responds to requests from SHC 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.

  • Works collaboratively with the Director of Quality and the Director of Regulatory Affairs  

Investigation, Research and Report Preparation

  • Proactively assesses compliance risks for SGH, collaborates and communicates effectively with operational stakeholders, identifies approaches to mitigate or monitor risks, develops compliance performance metrics, participates in the development of SGH Board reporting for compliance, and recommends strategies to achieve and sustain an effective compliance, ethics and privacy program aligned to SHC Compliance goals.

  • Plan, execute, and manage investigations, engaging other SHC subject matter experts and consulting with VP of Corporate Compliance and legal counsel as needed to effectively manage timely and thorough reviews, maintain appropriate documentation, provide periodic updates to leadership (SGH and SHC) that include potential risk, escalating as appropriate.

  • Support design and implementation of corrective actions in conjunction with operations and other leaders to investigations and other issues generated by the compliance and privacy programs. Provide routine updates on progress, and/or corrective action status.

Committee Participation

  • Develop and serve as Chair for an SGH Compliance Committee ensuring stakeholder engagement, regular meetings, appropriate documentation, the discussion of relevant compliance activities, and escalation of key matters as needed.

  • Participate on the SGH RISC Committee as the Compliance member directing relevant dialogue and action planning.

  • Participate in system compliance and privacy committees as requested

  • Regulatory Compliance Knowledge

  • Maintain specific knowledge and skills related to the SHC Code of Conduct necessary to answer questions and provide guidance to hospital personnel on business compliance and ethics questions or concerns.

  • 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

Compensation and Benefits:

The position provides a very competitive compensation, including opportunity to participate in a management bonus incentive program along with a generous benefit package.

 

Please note: Unsolicited resumes from employment agencies or other third parties will not be considered.

 

“Sharp HealthCare is an Equal Opportunity/Affirmative Action Employer, we celebrate our employees’ differences.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender, gender identity, transgender status, sexual orientation, protected veteran status, among other things, or status as a qualified individual with disability. Different makes us better.”


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“After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it.”

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