SENIOR VICE PRESIDENT, CHIEF COMPLIANCE OFFICER (OBH)

Overview

The SVP/CCO provides centralized direction and oversight of OBH’s Corporate Compliance Program based on the Federal Sentencing Guidelines for Organizations. The SVP/CCO is responsible for identifying and assessing areas of compliance risk for OBH and its three hospitals: Interfaith Medical Center (IMC), Brookdale Hospital Medical Center (BHMC), and Kingsbrook Jewish Medical Center (KJMC). Compliance Program oversight also includes a pharmacy corporation, two diagnostic and treatment corporations, an extensive network of primary, behavioral health, and specialty care locations throughout Central Brooklyn and two large nursing homes: The Schulman and Schachne Institute for Nursing and Rehabilitation and Rutland Nursing Home. OBH also operates an assisted living program through The Brookdale Residence HDFC.

The SVP/CCO also communicates the importance of the Compliance Program to Executive Management and the Board of Trustees; prepares and distributes the OBH Code of Conduct; develops and implements education programs addressing compliance and the Code of Conduct; implements a retaliation-free internal reporting process, including an anonymous reporting system; and collaborates with Executive Management to effectively incorporate the Compliance Program within System operations and programs and to carry out the executive leadership responsibilities of the position.

The SVP/CCO is responsible for maintaining the effectiveness of OBH’s Corporate Compliance Program; serving as the primary corporate resource for Medicare/Medicaid reimbursement information; maintaining compliance with applicable federal and state rules; and acting as a consultative resource for reimbursement and regulatory issues throughout OBH.

The SVP/CCO has direct access to the Board of Trustees for the purpose of advising and making recommendations about regulatory compliance issues.

Responsibilities

Work diligently to foster a culture and climate of sensitivity to ethical and compliant behavior within OBH, including a culture of compliance.

Oversee, coordinate, and monitor the day-to-day compliance activities of the Compliance Office and supervise members of the Compliance Department, including tracking all issues referred to the Compliance Office.

Collaborate with Internal Audit to conduct a formal, regulatory risk assessment and commit high risk areas to an annual or biennial Compliance Work Plan, approved by the System Compliance Committee and Board of Trustees.

Regularly review the Compliance Program (at least annually) and develop and implement appropriate revisions and modifications to the Compliance Plan based on regulatory changes, changes in interpretations of applicable laws, and industry trends related to compliance. This includes review of the Code of Conduct, compliance policies and procedures, the compliance education and training program, and other

Implement an effective compliance program that appropriately includes all seven elements of an effective compliance program

Advise administrative leadership and the Board of Trustees of potential compliance risks facing the System.

Identify the appropriate resources necessary to manage the OBH Compliance Program and establish and manage a budget to support such resources.

Implement, operate, publicize, and monitor retaliation-free reporting channels, including an anonymous reporting system available to all employees, volunteers, and affiliated providers.

Ensure that allegations of noncompliance are promptly investigated and responded to.

Develop compliance-related educational programs for all employees, agents, affiliated providers, or others working with the System.

Ensure that internal controls are capable of preventing and detecting instances or patterns of illegal, unethical, or improper conduct by employees, agents, affiliated providers, or others working with OBH components.

Coordinate internal investigations of alleged violations of ethics and compliance standards, including working with Legal and/or outside legal counsel, as appropriate, to conduct, authorize, or oversee investigations of matters determined to merit investigation under the Compliance Program.

Oversee follow-up and, as applicable, resolution to investigations and other issues generated by the Compliance Program, including development of corrective action plans, as needed.

Interact with regulators on compliance issues.

Review all internal compliance, audit reports, and investigation reports pertaining to OBH.

Develop productive working relationships with Legal, Human Resources, Internal Audit, Finance, Information Technology, Clinical, and others, to effectively communicate ethics and compliance standards to all departments at OBH components and serve as a compliance resource.

Present quarterly and annual reports on the Compliance Program to the System Compliance Committee and Board of Trustees employing compliance metrics as measurements on how well the Compliance Program is operating

Report on a regular basis to the System Compliance Committee on matters involving the Compliance Program, including directing the development of appropriate agendas, reports, and information as agreed upon by the committee.

Serve as a member of the System Revenue Cycle Committee to identify potential compliance issues and serve as a resource for the committee.

Provide oversight of compliance with grants.

Oversee HIPAA privacy compliance by serving as the privacy officer or being the direct supervisor of the privacy officer.

Coordinate and support, with senior management, corporate monitoring and auditing procedures of clinical practices, including clinical quality.

Participate in local and national compliance education and networking programs for healthcare compliance and privacy officers.

Perform other duties as assigned by the CEO and the Board of Trustees.

Qualifications

Education:

Master’s degree, post-graduate degree or Juris Doctor degree

Licenses and Certifications:

Certification in Healthcare Compliance

Experience:

Minimum eight (8) years of healthcare compliance leadership experience

Knowledge and Skills:

Background in Medicare and Medicaid reimbursement and fraud and abuse law

Knowledge of population health and public health programming;

Experience with establishing timelines and accountability measures for work completed by internal and external partners;

Experience with stakeholder engagement including coordinating advisory groups;

Experience serving as a liaison between internal partners, stakeholders

Physical Requirments:

Position requires prolonged periods of standing, reaching, walking throughout the working day.

Position will be required to stoop, bend, lift, and carry items weighing up to 25 pounds.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions without compromising patient care.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of One Brooklyn Health System (OBHS), and Interfaith Medical Center (IMC).

One Brooklyn Health System (OBHS), and Interfaith Medical Center are an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.