Director of Compliance

4 weeks ago

Morristown, United States Atlantic Health System Full time

Position Summary

Responsible for all aspects of the organization’s corporate compliance program and associated fraud, waste, and abuse prevention initiatives:


Key Responsibilities

  • Manage the day-to-day activities, including the supervision of assigned direct and indirect reports, of the Compliance Division of the AHS Corporate Compliance and Internal Audit Department.
  • Develop and update written internal standards of conduct and associated policies, procedures, and guidance pertaining to the implementation of the AHS Compliance and Ethics program and related fraud, waste, and abuse prevention initiatives.
  • Oversee the maintenance of the organizational-wide compliance reporting process and associated organizational-wide confidential and anonymous compliance hotline.
  • Provide, from a compliance perspective, oversight of organizational-wide privacy including, without limitation: (i) (a) HIPAA Privacy and Breach Notification Rules compliance; and (b)applicable State privacy law pertaining to patient information, employee information, and protected personally identifiable information, as well as applicable Federal and State privacy breach notification rules compliance; (ii) data breach determinations and follow up; (iii)investigations; (iv) risk assessment and analysis; (v) internal and external reporting; (vi) HIPAA training framework and program; (vii) the management and monitoring of business associate agreements and associated processes; and (viii) digital privacy compliance-related matters.
  • Develop and conduct organizational-wide compliance-related training and education for AHS new team member team member orientation, as well as for annual and ad hoc compliance training.
  • Prepare agenda materials for, and report out at, the various AHS Hospital’ compliance committees, as well as other compliance-related committees as directed by the VP of Corporate Compliance and Internal Audit, covering compliance program activities and associated metrics.
  • Develop and perform focused audit-related activities including, without limitation, the conduct of compliance reviews, the assessment of existing internal controls, and the performance of gap analyses, concerning organizational risk areas (whether such risks are predefined by regulation or regulatory guidance, or identified through organizational experience) for legal and regulatory compliance.
  • Develop and lead the ongoing (at least annual): (i) assessment of organizational-wide risks, including risk identification, scoring, prioritization activities; and (ii) championing, coordination, and facilitation of enterprise risk management activities.
  • Conduct, manage, and document investigatory activities in response to compliance-related complaints and concerns.
  • Perform ongoing and annual effectiveness assessments of the AHS Compliance Program.
  • Required JD from an ABA accredited law school is required with admission to practice law in at least one U.S jurisdiction required (Admission to NJ Bar preferred).



Experience Required

  • 10+ years' compliance experience. (5+years' experience in healthcare)
  • Ability to collaborate and possess strong business judgement
  • Manage and coach team and processes projects


Education Required

  • JD from an ABA accredited law school is required with admission to practice law in at least one U.S jurisdiction required (Admission to NJ Bar preferred).
  • Certification in Compliance and Ethics or Healthcare Compliance by the Compliance Certification Board (“CCEP” or “CHC” designation, respectively) is required at the time of appointment, with CHC designation being preferred.
  • Certification as an Information Privacy Professional by the International Association of Privacy Professionals (“IAPP”)(“CIPP-US” designation), or a related certification issued by IAPP, Compliance Certification Board, ISACA or ISC2, is preferred.

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