Executive Director Compliance & Privacy

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This is a Stanford Health Care job.

A Brief Overview
Reporting to the Senior Vice President (SVP) Chief Compliance and Privacy Officer in the Office of Compliance and Privacy the Executive Director Compliance and Privacy is responsible for implementing and managing the Compliance and Privacy Programs for Stanford Health Care (SHC) and Stanford Medicine Childrens Health (SMCH) (collectively referred to as the Stanford Health Entities). This role is essential for maintaining the integrity and privacy of patient information supporting compliance with relevant laws handling privacy complaints and maintaining and disseminating the notice of privacy practices. Leads and manages the organizational compliance and privacy programs to continuously assess their overall effectiveness.

This role involves addressing the day-to-day compliance and privacy issues responding to inquiries and complaints conducting internal investigations and enhancing operational controls to meet state and federal laws providing early warnings about new laws and regulations or initiatives by external agencies and coordinating with stakeholders across Stanford Medicine including Stanford Universitys Office of the Chief Risk Officer and Stanford Universitys Chief Privacy Officer. The Executive Director Compliance and Privacy will supervise a team of compliance and privacy professionals in the SHC/SMCH Office of Compliance and Privacy.

The Executive Director Compliance and Privacy addresses issues related to electronic health records (EHR) policies and procedures oversees the proper release of information and manages electronic media development among other duties and responsibilities relating to compliance and privacy within the Office of Compliance and Privacy.

Locations
Stanford Health Care

What you will do

• Develops and implements written policies procedures and standards of conduct.

• Educates and conducts training that promote a culture of integrity and ethical conduct.

• Develops effective lines of communication regarding compliance and privacy; receives complaints and provides information regarding compliance and privacy matters. This includes the management of incident and inquiry intake through various reporting channels triage and resolution.

• Leads and facilitates internal investigations of compliance and privacy issues and promotes consistency of standards through disciplinary guidelines.

• Monitors external industry regulatory and privacy trends to inform and advise the Chief Compliance and Privacy Officer and other senior leaders.

• Identifies assesses and mitigates risks related to fraud waste and abuse through proactive monitoring and collaboration with the Office of General Counsel and the Office of the Chief Risk Officer.

• Supervises a team of Compliance Program Management and Privacy Compliance professionals.

• Recruits retains and develops a team of professionals creating and maintaining a highly engaging work environment.

• Prepares and provides periodic reports to the Stanford Health Entities Compliance Committees including the Corporate Compliance Committee the Executive Compliance Committee the Audit Compliance and Enterprise Risk (ACER) Committees of the Boards of Directors and other organizational committees.

• Assists the SVP Chief Compliance and Privacy Officer with the management of the Stanford Health Entities committees that address compliance and privacy issues by addressing matters of potential non-compliance and researching and providing analysis on applicable laws and regulations and corrective action if necessary.

• Communicates effectively to facilitate positive working relationships and achieve desired outcomes; serves as a positive role model and effective liaison for SHC SMCH and all relevant covered entities including faculty physicians and other health entity leadership and staff to achieve increased satisfaction with and participation in the privacy program components.

• Oversees and conducts complex high-risk investigations and reviews prepares formal responses to external federal and state investigations and advises on corrective action and subsequent monitoring plans including the mitigation of any known harmful effects to patients.

• Develops long-range and short-term goals objectives and plans to support the development implementation maintenance and improvement of program effectiveness.

• Serves as a liaison to the University regarding SHC/SMCH compliance and privacy matters in collaboration with the SHC/SMCH Chief Compliance Officer and Privacy Officer and plays a collaborative and supportive role when interacting with the Universitys Chief Privacy Officer and the University Privacy Office on matters requiring joint coordination and collaboration.

• Ensures policies procedures and processes are created and implemented to support patients privacy rights including access to medical records amendment of medical records accounting of disclosures of medical information requests for restrictions of the use and release of medical records requests for confidential communications filing of complaints about privacy practices and maintenance and dissemination of the Notice of Privacy Practices.

• Obtains sufficient competent and relevant regulatory documentation to afford a reasonable basis for analysis judgment and conclusions; stays current with applicable government rules and regulations and maintains current privacy information.

• Provides leadership skills to accomplish Stanford Health Care Entities mission goals and strategic plan.

• Responds to and oversees the process of compliance and privacy intake through all sources including the Compliance Programs various hotlines of all inquiries issues concerns and complaints from employees providers patients and external parties; conducts investigations and interviews as necessary; oversees the intake tracking corrective action and documenting through resolution

Education Qualifications

• Bachelors degree in a work-related discipline/field from an accredited college or university Required

• Advanced degree in healthcare healthcare administration or law Preferred

Experience Qualifications

• Ten to fifteen (10-15) years of compliance and privacy program management responsibility in a complex multi-organizational healthcare environment

• At least seven to ten (7-10) years of supervisory responsibility

• At least four to seven (4-7) years of experience working in the State of California and strong working knowledge of California law and regulations

Required Knowledge Skills and Abilities

• Experience in operationalizing a successful compliance and privacy program particularly within a large academic medical center or health care setting of similar size and complexity including the development of risk assessments and workplans.

• Ability to effectively prioritize work communicate progress and meet deadlines by producing accurate work products in a fast-paced environment.

• Ability to maintain competence in and up-to-date knowledge of healthcare compliance requirements practices and trends.

• Ability to maintain confidentiality of all information particularly sensitive information.

• Ability to model and demonstrate consistently high standards of professional ethics integrity and trust.

• A proven track record of strong teamwork and leadership skills within and across other organizational departments.

• Ability to perform research and analysis of health care laws regulations and policies as well as compliance issues.

• Ability to effectively communicate with all levels of the organization.

• Ability to chair relevant committees and engage in productive focused and meaningful discussion.

• Demonstrated and proven maturity and highly professional skills to instill the trust and confidence of key stakeholders.

• Ability to demonstrate meaningful leadership and management attributes.

• Ability to manage direct and evaluate the work of others as well as develop and retain talent.

• Ability to identify problems and provide timely relevant solutions.

• Ability to understand interpret and apply complex federal and state hospital compliance laws rules regulations and guidelines.

• Proven ability to use sound judgment and make sound decisions.

• Knowledge of and practical experience in working with global federal and state privacy and compliance laws and regulations OIG DOJ and U.S. Department of Health and Human Services Office of Civil Rights enforcement methods and other applicable federal and state compliance and privacy guidance and industry best practices including but not limited to the compliance program industry standards best practices and industry guidance.

• Knowledge of the organization and functioning of hospitals emergency departments and ambulatory care clinics.

• Knowledge of principles and practices of organization administration fiscal and personnel management.

• Knowledge of theories principles and practices of strategic planning program evaluation and improvement and budget development and analysis.

• Proven track record of successfully conducting complex compliance and privacy internal investigations into multiple areas including billing and coding compliance quality of care and patient safety privacy and security and conflicts of interest the Medicare Conditions of Participation and Conditions of Payment Title 22 Stark PORA state and federal False Claims Acts and the Anti-Kickback Statute.

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients families and towards each other. C-I-CARE is the foundation of Stanfords patient-experience and represents a framework for patient-centered interactions. Simply put we do what it takes to enable and empower patients and families to focus on health healing and recovery.

You will do this by executing against our three experience pillars from the patient and familys perspective:

• Know Me: Anticipate my needs and status to deliver effective care

• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination inall ofits policies and practices including the area of employment. Accordingly SHC does not discriminate against any person on the basis of race color sex sexual orientation or gender identity and/or expression religion age national or ethnic origin political beliefs marital status medical condition genetic information veteran status or disability or the perception of any of the above. People of all genders members of all racial and ethnic groups people with disabilities and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

The salary of the finalist selected for this role will be set based on a variety of factors including but not limited to internal equity experience education specialty and training. This pay scale is not a promise of a particular wage.