Identify regulatory compliance obligations of the Division of Health Sciences, its administration and employees on topics such as: billing and accounting for clinical service; documentation, medical records and coding; licensure and credentialing; False Claims Act Violations; etc.
Maintain a comprehensive corporate compliance program and an ongoing corporate compliance plan for the Division of Health Sciences.
Provide guidance and assistance, in consultation with the Office of University Counsel, in the preparation of written guidelines, policies, procedures, and standards of conduct on specific legal and regulatory issues involving medical, business and administrative practices for the Division of Health Sciences.
Develop and oversee the implementation of timely applicable educational training programs for employees and administrative officials to ensure sufficient understanding of relevant federal and state law regulations and institutional policies within the purview of the Office involving compliant business and clinical practices.
Develop effective lines of communication throughout the institution to enhance effectiveness of the compliance program, including practices and policies that encourage reporting incidents of noncompliance without fear of retaliation.
Coordinate the timely investigation of credible information and allegations concerning possible non-compliance with applicable laws, rules and regulations, or inappropriate activities within the purview of the Office and which involve the Division of Health Sciences administration or employees.
Coordinate regular compliance assessments and monitoring of institutional operations to identify and rectify barriers to institutional and individual compliance with applicable law, rules and regulations.
Recommend corrective action and/or appropriate discipline when incidents of non-compliance are confirmed.
Work collaboratively with the Office of University Counsel, BSOM Office of Risk Management, East Carolina University offices of compliance, risk management, human resources and internal audit, and with Vidant Health offices of risk management, compliance and privacy.
Revise the institutional compliance program in response to changes both in the needs of the institution and in the law, policies and procedures of government and private payer health plans.
Develop and grow a climate of compliance in which the Office seeks collaborative relationships that support the work of the Division's employees and learners in fulfilling their work assignments in a manner fully compliant with regulatory requirements.
Serve as the chief administrator of the Office of Compliance, providing supervision to all employees and with accountability of all aspects of the finances and work product of the Office.Oversee and develop Office goals, objectives, annual workplan and budget.
Prepare and supervise the distribution of:
A written code of conduct for BSOM setting forth the ethical principles upon which individual behavior and institutional policies should be based; A structured, detailed and explicit compliance program; and A written and ongoing compliance plan.
Make presentations on the compliance program to the Division of Health Sciences administration, the ECU Physicians Board of Directors, and other officials as needed.
Develop successful compliance solutions that respond to available assessments of the Division of Health Science compliance activities, OIG Annual workplans, and other relevant directives and guidance from regulatory bodies.
Work collaboratively with appropriate staff, departments, offices and schools to develop and update policies and practices that promote compliance in areas such as, but not limited to:
Documentation, medical records and coding Anti-trust Billing and accounting for clinical services False Claims Act violations Utilization review policies Kickbacks/Self-Referrals Relevant Conflict of Interest requirements
Ensure processes to develop and publicize policies that clearly outline employees' affirmative duty to report suspected compliance offenses through established and well-defined channels to appropriate institutional authorities.
Develop, maintain and publicize clear and efficient procedures to receive and document reports of suspected non-compliance, via Compliance Hot Line and/or other appropriate means.
Maintain up to date procedures by which the Office will coordinate investigations and resolve suspected compliance violations, including recommendations for corrective action which may include restitution, disciplinary action against responsible parties, and/or reporting to appropriate governmental bodies and enforcement officials, the Division of Health Sciences and ECU administration, and ECU Office of the Internal Audit and Management Advisory Services. Where applicable, assure that investigations are handled collaboratively with other administrative offices within ECU. Reporting offenses to governmental bodies will be completed in consultation with the Office of University Counsel.
Work with other officials at the University to ensure that individuals involved in research fulfill their regulatory responsibilities.
Evaluate educational needs regarding compliance issues throughout the institution. Oversee the development and operation of formal compliance educational programs for employees that address both a broad institutional code of conduct and specific compliance policies, procedures and guidelines for components of the division.
Training should enable employees to identify issues as they arise and report them appropriately. Collaborate with other offices when developing compliance educational materials to coordinate trainings, minimize duplication, and ensure appropriate audiences are reached.
Ensure that processes for informing independent contractors and other agents who furnish services to or on behalf of the Divions of Health Sciences about the divisions compliance program and agree to work within its guidelines.
Supervise the preparation and submission of reports to the Division of Health Sciences leadership which will include a detailed discussion of the Office's activities including, but not limited to: specific results of assessment and monitoring activities; identified deficiencies and remedies; identification of new or newly discovered compliance risks; new policies or implemented programs; progress on the previous year's goals; plans for the impending year, etc.
These reports will also be appropriately provided to the ECU Board of Trustees.RESPONSIBILITIES AS HIPAAPRIVACYOFFICER
Identify regulatory compliance obligations of ECU regarding HIPAA for all relevant employees and learners.
Maintain a comprehensive HIPAA compliance and education program for the health care components of ECU and other units as appropriate.
Serve as HIPAA privacy consultant to the University for all departments and appropriate health care components.
Provide leadership, guidance and assistance, in association with the Office of University Counsel, in the preparation of written guidelines, policies, procedures, and standards of conduct on specific legal and regulatory issues involving medical, business and administrative practices at ECU as related to HIPAA requirements.
Develop and oversee the implementation of timely educational training programs for employees and administrative officials to ensure sufficient understanding of relevant federal and state law, regulations and institutional policies involving ethical, legal, business and clinical practices dealing with HIPAA.
Oversee the delivery of initial orientation and annual HIPAA privacy training for all employees, volunteers, medical and professional staff, contractors, alliances, and other appropriate third parties as required.
Oversee and promote activities to foster information privacy awareness within the University and related entities.
Develop effective lines of communication throughout the institution to enhance effectiveness of the HIPAA compliance program, including practices and policies that encourage reporting incidents of noncompliance without fear of retaliation. This will include fostering a climate of collaboration and active engagement with employees and learners in which fully compliant solutions to their needs are developed and implemented.
Coordinate regular HIPAA compliance assessments and monitoring of institutional operations to identify and rectify barriers to institutional and individual compliance with applicable law, rules and regulations.
Collaborate with management and other operational units on a mechanism to track access to protected health information, within the purview of the University and as required by law.
Establish and administer a process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the University's HIPAA privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, the Office of University Counsel.
Collaborate broadly with others to facilitate compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the University's workforce, extended workforce, and for all business associates, in cooperation with Human Resources, the HIPAA security officer, ITCS, compliance, risk management, administration, and the Office of University Counsel as applicable.
Cooperate with other ECU officials in responding to queries or filings from the U.S. Office for Civil Rights, other legal entities, and organization officers in any HIPAA compliance reviews or investigations.
Work collaboratively with the Office of University Counsel, Division of Health Sciences Office of Compliance, BSOM Office of Risk Management, East Carolina University offices of compliance, risk management, Human Resources internal audit, and ITCS, and with Vidant Health offices of HIPAA Privacy and compliance.
Special Instructions To Application:
East Carolina University requires applicants to submit a candidate profile online in order to be considered for the position. In addition to submitting a candidate profile online, please submit online the required applicant documents:
Curriculum Vitae Letter of Interest List of Three References (noting contact information)
Master’s Degree, its equivalent, or higher, in nursing, law, healthcare administration, finance, medicine, or related discipline from an appropriately accredited institution.
Five years of experience or more in clinical or healthcare administration settings.
Three years of experience or more in compliance or HIPAA privacy in medical school, hospital or other healthcare settings.
Basic understanding of the general principles of health care law, compliance, and risk management.
Specific knowledge of the relevant key laws and regulations governing health care compliance, including areas such as HIPAA, Medicare and Medicaid, research compliance, regulations relating to physicians in teaching hospitals, etc.
Excellent written and verbal communication skills and report preparation skills.
Supervisory experience/ability and leadership style that emphasizes teamwork, communication, collegiality, flexibility, and fostering success for each employee in the office.
Full time or Part time: Full Time
Position Location (city): Greenville
Position Number: 952629
Organizational Unit Overview:
The Office of Compliance (Office) is responsible for overseeing the maintenance, implementation, revising and enhancing of mechanisms that ensure that the Division of Health Sciences complies fully with applicable federal, state, and University laws, regulations, policies and procedures relevant to all aspects of its operations.
While there is special emphasis on the regulatory requirements for the clinical operations of the Brody School of Medicine (BSOM) and the School of Dental Medicine (SODM), the role is not limited to those schools or their clinical enterprises.
The Office's responsibility is focused both on compliance with the law and also in the creation and maintenance of an organizational culture committed to ethical behavior, as led by the executive leadership of the Division of Health Sciences.
The Chief Institutional Integrity Officer guides and oversees the operation of the Office including the design, implementation, monitoring and assessment of Division-wide compliance activities.
The Chief Institutional Integrity Officer reports directly to the Associate Vice Chancellor for HealthCare Regulatory Affairs for all compliance activities related to the Division. The Chief Institutional Integrity Officer also serves as the University's HIPAA Privacy Officer; in this role, the CIIO reports to the Vice Chancellor for Health Sciences.
Because the Office of Compliance's responsibility includes guidance and oversight over all levels of division administrative and clinical operations, and over all division employees and administrative officials, the CIIO, where necessary and appropriate, will provide reports to the Health Sciences Senior Academic Officers, Health Sciences Deans, the ECU Physicians Board of Directors, the Vice Chancellor of Health Sciences, and other administrative officials at ECU.
The Chief Institutional Integrity Officer will provide the following essential leadership functions for all personnel in the Office:
Act as the chief administrator of the Office, providing supervision to all employees and accountability for all aspects of the Office.
Mentor, lead and support the staff of the Office, with appropriate delegation and distribution of duties and tasks to maximize efficiency, responsiveness and availability of all members of the office.
Maintain current knowledge of applicable federal and state privacy laws and accreditation standards, and monitor advancements in HIPAA information privacy technologies to ensure University adaptation and compliance.
To be a national model for student success, public service and regional transformation, East Carolina University uses innovative learning strategies and delivery methods to maximize access; prepares students with the knowledge, skills and values to succeed in a global, multicultural society; develops tomorrow's leaders to serve and inspire positive change; discovers new knowledge and innovations to support a thriving future for eastern North Carolina and beyond; transforms health care, promotes wellness, and reduces health disparities; and improves qualify of life through cultural enrichment, academics, the arts, and athletics. We accomplish our mission through education, research, creative activities, and service while being good stewards of the resources entrusted to us. East Carolina University delivers on the promise of opportunity. We open doors. We improve lives. We transform the present, and we discover the future. In these ways and more, we serve our community, our state, our nation and our world as together we reach toward our greatest potential. Tomorrow starts here.
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