Chief Compliance and Privacy Officer-QA500801

This position serves as a leader on ICL's executive team, providing strategic and operational advice to the President and CEO to ensure that the organization can help our clients get better across all programs consistent with the mission, commitment, and core values of ICL as well as provisions required by laws, regulations, and accreditation standards. The CCPO leads the design, development, implementation, and maintenance of the enterprise-wide compliance, risk management system, policies and procedures development, and standardization of processes.

ESSENTIAL JOB FUNCTIONS:

Corporate Compliance

• As a member of the executive team the CCPO informs, educates, and champions the principles of the ICL's Corporate Compliance Plan.
• Coordinates planning and implementation of system-wide programs, policies, and procedures to ensure system compliance with all applicable laws and regulations.
• Develops and maintains corporate compliance plan and procedures for implementation
• Oversees, develops, and implements compliance training for all staff including written materials and programs designed to promote an understanding of laws and regulations, as well as consequences of non-compliance.
• Develops, implements, and maintains a system for confidential reporting and investigation of compliance concerns with an appropriate response process, including coordination of an external compliance reporting system allowing for anonymous, non-retaliatory compliance reporting. Establishes controls/measures for an effective compliance program that includes development and maintenance of internal audit controls and processes, ensuring accurate, complete, and compliant programs across the system.
• Oversees internal investigation activities of alleged abuse, neglect, fraud, and waste
• Serves as the organizations point person in collaboration with federal, state, and local authorities regarding investigations.
• Follows obligation and empowerment to report directly to the Board of Directors if the CEO is suspected of being complicit in fraud, waste, abuse, or other illegal activity.
• In collaboration with the SVP's and Executive team, provide overall direction to ensure services are provided in accordance with standards established through state and federal regulations, the Center for Medicare and Medicaid Services, and other relevant accreditation agencies.
• Review and analyze quality metrics and make recommendations for process improvements.
• Prioritize the deployment of process improvement efforts to achieve maximal gain in client outcomes.
• Help facilitate the root cause analysis process regarding unexpected client outcomes.

Internal Auditing and CARF Accreditation

• Develops and oversees annual Compliance Work Plan.
• Develops and implements an annual audit plan using an appropriate risk-based methodology, incorporating concerns identified by management and Board of Directors and monitors internal audit reports.
• Oversees ICL's CARF Accreditation preparation process and survey
• Submit trends analysis reports to the executive staff, board committees, or other identified standing and ad hoc committees
• Provides oversight to corporation's incident reporting and management systems, including oversight of Incident Review Committee meeting proceedings.
• Monitor compliance metrics and performance indicators to assess the effectiveness of privacy and complaint management initiatives.
• For quality improvement purposes, issues periodic reports to the CEO and executive team members summarizing results of audit activities.
• Keeps the Board of Directors informed of emerging trends and successful practices in internal auditing.

Risk Management

• Develops and implements the organization's Enterprise Risk Management Program, ensuring fulfillment of the mission and strategic goals of the organization, as well as compliance with state and federal laws and accreditation standards.
• Develops and implements systems, policies and procedures for the identification, collection, and analysis of risk-related information.
• Submit trends analysis reports to the executive staff, board committees, or other identified standing and ad hoc committees
• Collects, evaluates, and maintains data concerning client injuries, claims, worker's compensation, and other risk-related data.
• Investigates and analyzes root causes, patterns, or trends that could result in loss and/or exposure.
• Conduct privacy impact assessments for new initiatives, systems, or processes to evaluate potential privacy risks and recommend appropriate controls.
• Assists in processing summons and claims against the facility by working with legal counsel to coordinate the investigation, processing, and defense.

Process Standardization

• Working with leadership and other staff, designs, analyzes and improves systems and processes that reduce waste and improve value.
• Identify opportunities for improvement in complaint handling processes, privacy practices, and staff training, and implement changes as necessary to enhance overall effectiveness and efficiency
• Adopts and champions the principles of Six Sigma: 1) Always focus on the customer, 2) Understand how work really happens, 3) Make your processes flow smoothly, 4) Reduce waste and concentrate on value, 5) Stop defects through removing variation, 6) Get buy-in from the team through collaboration, and 7) Make your efforts systematic and scientific.

Other Responsibilities

• Represents the agency at relevant conferences by designing and presenting educational materials and activities that promote quality improvement or corporate compliance.
• Oversees, participates in, and conducts Root Cause Analyses on sentinel and other significant events in programs as needed.
• Adhere to, foster, and promote ICL’s values of ethical integrity, compassion, equity and inclusion, accountability, quality, growth and mastery, in all aspects of complaint handling and patient privacy management.
• Supervises and provides mentorship to staff and practicum or internship students.

ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Committed to equity, diversity, inclusion and belonging, and active promotion of the ICL values and goals.
• Knowledge of internal auditing standards and practices and risk management standards and practices and experience overseeing or conducting internal audits.
• Critical thinking, change management skills and approaches.
• Data driven decision maker.
• Excellent interpersonal skills.
• Excellent oral and written communication skills.
• Ability to accurately interpret and implement regulatory standards.
• Knowledge of reimbursement systems and third-party payer requirements.
• Knowledge of regulations, standards, policies, and requirements pertaining to clinical documentation, coding, and billing.
• Ability to interpret legal requirements.

LEADERSHIP STYLE & CHARACTERISTICS:

• Lead with Empathy: Demonstrate and foster, by example, a supportive, nurturing, and inclusive environment for clients and staff. Demonstrates high level of motivation, professionalism, and trustworthiness. Places a high value on treating others with dignity and respect
• Vision and Purpose: Embrace and communicate ICL's vision, its goals, and its business needs; dedicated to success; inspire and motivate; operate without ego.
• Inspirational: Encourage and inspire colleagues and team members to stretch beyond what they thought they could accomplish.
• Diversity: Demonstrated commitment of the value of diversity and inclusion with the ability to and interest in working with diverse employees and recipients of services.
• Leadership: Be bold enough to diplomatically state opinions which may not always be popular. Ability to work through controversy turning conflicts into opportunities for improvement and striving for win/win resolutions.
• Ethics and Values: Embrace IC L's values with a focus on what's best for the clients.

QUALIFICATIONS AND EXPERIENCE:

• Master's degree or doctorate in psychology, education, social work, health/public health administration or related field.
• Ten years of progressively more responsible Quality Assurance or Corporate Compliance experience within health care and/or health-related fields. This experience should involve the administration, design, and supervision of an integrated quality assurance program within social service systems of substantial size.
• Strong knowledge of laws and regulations imposed on health care systems by various agencies including Federal, New York State, and New York City. Experience with CARF Accreditation process, implementing or participating in risk management activities and experience leading, managing and developing a team. Green belt or higher in Six Sigma preferred.