This position provides leadership and direction for Compliance and Privacy for the Accountable Care Organization (ACO) as well as providing oversight and direction to the Joint Venture Compliance Program and Security Compliance program.
This position is responsible for the development and approval of the annual ACO work plan as well as the ACO monthly audits. The incumbent will prepare and present reports to the ACO Board. This position is also responsible for ensuring the CHRISTUS Health Joint Ventures have effective compliance programs through an attestation process, among other things. Additionally, the Director of Compliance is responsible for ensuring the development of a security compliance work plan and that associated audits are completed within deadlines. This position is also responsible for developing an annual work plan for the Assisted Living Facility and interacting with the leadership to conduct work plan audits.
As Director of Compliance, this position will serve as a role model along with all other CHRISTUS leaders for behavior consistent with the Mission, Vision, and Core Values of CHRISTUS Health.
This position is responsible for assisting the Vice President of Corporate Compliance and System Director of Compliance and Privacy with the development of the annual compliance work plan as well as auditing a sample of regional work plan audits to ensure accuracy and ensure internal controls are effective. This position will also assist the Compliance Audit Manager with the development of work plan templates, as required.
Maintain and implement a comprehensive compliance program for the ACO which ensures compliance with regulatory requirements
Implement processes and procedures to maintain a current, active, and effective compliance program for the ACO
Research CMS regulations for the ACO's, develop work plan, and perform monthly audits according to the work plan calendar
Ensure corrective action plans (CAP'S) are implemented and resolved for deficiencies identified in the work plan audit
Ensures timely completion of annual compliance and privacy education for ACO providers and suppliers
Prepare and present compliance reports to the ACO Board
Review state regulations for Assisted Living Facilities, develop work plan and work with Assisted Living Facility CEO to perform audits as designated on work plan calendar
Provide oversight to the Program Manager for Joint Ventures to ensure attestations are completed annually and supporting documents are received from the joint venture demonstrating an effective compliance program
Provide oversight to the Program Manager for Security Compliance to ensure that the annual work plan and calendar are prepared and monthly audits are preformed and summarized and Coorective Action Plans are implemented and resolved.
Assist the Vice President of Corporate Compliance and System Director of Compliance and Privacy with development of the annual compliance and privacy work plan
Assist Compliance Audit Manager with developing monthly work plan templates and identifying and developing controls to support CAPs, as needed
Review a sample of monthly audits for each region to validate the audit process and results and that internal controls are in place
Prepare monthly summary of quality assurance review findings and present findings to the Vice President of Corporate Compliance and System Director of Compliance and Privacy
Prepare list of outstanding CAP'S and the status of each CAP and communicate with regions until the CAP is completely resolved
Bachelor's Degree required
Master's degree in business/health care field preferred
Knowledge of Compliance and HIPAA Privacy
Working knowledge of ACO's and hospital operations
Knowledge of audit and investigation techniques
Strong interpersonal skills, including the ability to interact effectively with Executives, ACO Board, facility management and Associates, Corporate Associates
Ability to make independent decisions as necessary
Attention to detail
Effective skills in team-building, shared decision making and change management
Minimum of 7 years demonstrated experience leading health care regulatory and compliance functions.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.
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