Under the direction of the Vice President and Chief Compliance Officer, the Director of Compliance Operations and Governance will direct, organize, and assist Christiana Care Health System (CCHS) in maintaining compliance with applicable laws, regulations and policies. They will have overall responsibility for directing compliance operations and ensuring appropriate governance of compliance matters for the Compliance Office. They will review workflows, documentation standards, policies and procedures, and communication to ensure adherence to the CCHS code of conduct and applicable compliance policies and procedures. This role will oversee the compliance office operations and ensure compliance governance is centralized, consistent and proactive.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Oversees all compliance-related education and training curricula, including, but not limited to fraud, waste and abuse. Develops systems to document, track and trend compliance education and training throughout the health system.

• Monitors the status and activities for each of the compliance elements to reasonably ensure adherence to applicable federal and state regulations, institutional policies and the compliance plan.

• Advises the organizations employees, contractors and vendors (as appropriate), agents on issues of operational compliance and governance standards and requirements.

• Supervises all compliance office conducted investigations of suspected violations received through the compliance hotline and other channels. Maintains documentation and trends for all health system compliance related investigations.

• Oversees the follow-up and implementation of corrective actions to investigations and other compliance issues. Maintains documentation of all compliance corrective actions and ensures appropriate monitoring is implemented and documented. Coordinates reviews of corrective action strategies to ensure effectiveness.

• Assists in the coordination of any internal and external compliance audits at the facility. Ensures audits are conducted in accordance with guidelines and is documented appropriately.

• Directs and supports activities of the Corporate Compliance Office related to compliance operations and governance.

• Conducts, participates and maintains updated documentation for periodic compliance operations and governance self-assessments as required. Makes recommendations to improve compliance program.

• Ensures all facility staff receives the Code of Conduct and manages annual compliance program attestation program. Coordinates with business units to ensure transparency and consistency in reporting. Makes recommendations and implements changes to ensure compliance with Federal, State, local, payer, and institutional regulatory requirements.

• Participates in developing and implementing internal controls capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct.

• Participates in various facility committees to ensure compliance objectives are being met.

• Develops and guides budgetary activities for the Compliance Operations and Governance Division of the Corporate Compliance Office.

• Oversees the Conflicts of Interest program

• Oversees Compliance Policies and Procedures, code of conduct, risk assessments and workplans. Ensures timely updates and reviews as scheduled and required,

• Oversees the Corporate Compliance Office operations including, but not limited to, data management, education and training, analysis and reporting

• Oversees corporate compliance risk assessments and regulatory work plans documentation and trends.

• Partners with HR and Legal on Faculty misconduct complaints, investigations, and regulatory responses

• Oversees the thorough documentation and reporting of all compliance related activities

• Manages Corporate Compliance Operations Team

• Maintains current knowledge of compliance trends, issues and regulations

DIRECTION/SUPERVISION OF OTHERS:

Direct oversight of Compliance Operations Team.

DIRECTION/SUPERVISION:

Directly responsible to the VP, Chief Compliance Officer.

EDUCATION AND EXPERIENCE REQUIREMENTS

• Bachelor's degree required. Master's degree/Advanced degree preferred.

• Minimum eight (8)- ten (10) years' experience in healthcare.

• Minimum ten (10) years of related healthcare experience.

• Minimum five (5) years of compliance experience.

• Three (3) years of direct experience managing compliance and privacy operations in healthcare organization.

• Minimum three (3) years direct experience managing staff and building collaborative, effective teams with high emotional intelligence.

• Knowledge of privacy regulations.

• Direct experience managing projects.

EEO Statement: Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.

UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.