Manager - Compliance Program Management

Compliance Program Manager

Manages daily compliance program management operational activities, key compliance initiatives, compliance projects, and compliance program integrity standard work. Assists in the development and maintenance of a robust compliance program for Stanford Health Care, Stanford Children's Health, University Health Care Alliance and Packard Children's Health Alliance. Responsibilities include overseeing and conducting compliance investigations and providing compliance-related guidance across the enterprise; organizing, facilitating, and managing the Corporate Compliance Committees; organizing, facilitating and managing the annual Compliance Risk Assessment and Workplan processes and ongoing mitigation plans; identifying, researching and communicating regulatory requirements to key organizational stakeholders, including physicians and senior management; overseeing the Compliance Policy Manual, including policy development; creating compliance training content and materials; presenting compliance training to various audiences; creating dashboards and reports consistent with Stanford Operating System procedures, such as tracking and trending compliance program activities and developing metric-based standard work measurements and tools; and participating in other compliance program elements for the ongoing demonstration of scrutiny-readiness.

Proactively assist with the design, development, enhancement, and implementation of the Compliance Program that includes training, policies, investigations, auditing, and reporting. Manage the development and deployment of a deliberate compliance training, policy, and communications strategy and program that builds awareness of the program, processes, and policies pertinent to health care compliance. Contributes to the achievement of the Office of Compliance and Privacy's goals and objectives; adheres to departmental policies, procedures and standards; complies with organizational policies and procedures, governmental laws / regulations and accreditation standards. Identify and implement solutions to enhance and update the compliance policy governance framework, including the Code of Conduct revision, and compliance related training and communications. Effectively maintains collaborative working relationships to achieve increased satisfaction with and participation in the Office of Compliance and Privacy. Conducts thorough, timely, and fair compliance investigations and assesses the viability and severity of underlying concerns. Assists the Office of Compliance and Privacy's leadership and other appropriate individuals regarding corrective action recommendations concerning non-compliant behaviors; creates complete, accurate, and timely closure documentation of complaints from patients, staff, faculty, and others. Oversee the management of Compliance Program Management guidance processes, including the provision of guidance in the areas of Code of Conduct, policies and procedures, record retention and destruction, conflicts of interest, gifts, and physician arrangements. Manages intake of and response to calls that come into the institutional hotline, including anonymous calls, and apply institutional non-retaliation policies to protect callers. Manages preparation for and facilitation of the Corporate Compliance Committees and Compliance meetings and record keeping; organizing, facilitating, and managing the annual Compliance Risk Assessment and Workplan processes and ongoing mitigation plans. Proactively collaborates with Stanford Medicine leadership and stakeholders to serve as a subject matter consultant to clinical and operational teams in collaboration with the Office of General Counsel with working knowledge of key laws and regulations that apply to hospital and provider compliance, including, but not limited to, Anti-Kickback Statute, EMTALA, the Stark Law, Conflicts of Interest, Gifts and Entertainment, and Medicare and Medicaid program requirements. Develop written policies, procedures, and programs that promote compliance and oversees activities to promote adherence to these policies, procedures, and programs. Lead the internal transition to a new incident management and document management system and policy governance process. Prepares annual and ad hoc reports for the Audit and Compliance Committee of the hospitals' Board of Directors. Develops and delivers Compliance Program Management training; conducts analysis of current state training content and materials and maps to future state training content. Oversees Compliance Policy Manual and assists in performing ongoing risk assessments of compliance policies and procedures; identifies gaps and makes recommendations to address any gaps, including timeframes and resources; drafts new policies and edits existing policies. Represents the Office of Compliance and Privacy in organizational meetings; serves as compliance subject-matter expert. Participate in Office of Compliance and Privacy improvement projects. Supports the Chief Compliance Officer and other members of the Office of Compliance and Privacy leadership in responding to corporate responsibility or governmental investigations / reviews. Produces and maintains Compliance Program activity records, analytical reports and dashboards related to comprehensive Compliance Program activities. Tracks and tends Compliance Program activities; manages Compliance Program Management issues log and departmental dashboards and produces and manages timelines to ensure issue response deadlines are met. Annually identifies specific needs for self-development and implements a plan to achieve professional growth. Performs other related job duties and projects assigned by the Chief Compliance Officer and / or the Director of Compliance Program Management.

Education Qualifications

Bachelors degree in Healthcare or related field or combination of education / related experience required. JD or Masters Degree preferred.

Experience Qualifications

Minimum of three (3) to seven (7) years of progressively responsible and directly related work experience required.

Required Knowledge, Skills and Abilities

Knowledge and understanding of federal and state compliance program requirements. Strong knowledge of applicable federal, state and local laws, regulations and policies pertaining to health care compliance matters. This role will serve as a subject matter consultant and must have working knowledge of key laws and regulations that apply to hospital and provider compliance, including, but not limited to, HIPAA, Anti-Kickback Statute, EMTALA, the Stark Law, and Medicare and Medicaid program requirements. Knowledge of general computer applications, such as Excel, Access, Word, PowerPoint, and Visio. Ability to communicate effectively and persuasively, including excellent verbal and written communication skills. Ability to work effectively with individuals at all levels and varying backgrounds within and outside the organization. Ability to plan, organize, prioritize multiple tasks and work independently to meet deadlines. Ability for excellent precision and complex detail. Ability to analyze and develop solutions to complex problems. Ability to work effectively both as a team player and a leader. Ability to apply judgment and make informed decisions.

Licenses and Certifications

CHC - Certified Compliance Professional required within 1 Year.

These principles apply to ALL employees :

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 Stanford's 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 family's 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 in all of its 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.