Regulatory Compliance Manager - Utica Park Clinic Quality Improvement

Hillcrest HealthCare System (HHS) is a comprehensive health system providing quality healthcare in northeastern Oklahoma, with the system’s flagship hospital, Hillcrest Medical Center, located in Tulsa. Additionally, HHS is comprised of Bailey Medical Center, Hillcrest Hospital Claremore, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, Hillcrest Hospital Pryor, Hillcrest Hospital South, Tulsa Spine & Specialty Hospital, Oklahoma Heart Institute and Utica Park Clinic. HHS has 1,180 licensed beds and an expansive network of clinics.

Ardent Health Services owns and operates Hillcrest HealthCare System. Based in Nashville, Tennessee, Ardent Health Services includes 30 hospitals and more than 200 sites of care.

Utica Park Clinic

Utica Park Clinic, founded in 1982, is a multi-specialty medical group with 325 employed physicians and advance practice providers representing 30 specialties.  They are made up of 55% primary care, 25% surgical specialties and 20% medicine specialties across 70 office sites in Oklahoma, serving 17 communities.  Annually, Utica Park Clinic sees approximately 260,000 unique patients with over 700,000 visits.

Oklahoma Heart Institute 

From comprehensive diagnostics to open heart surgery and cardiac rehabilitation, Oklahoma Heart Institute combines recognized cardiovascular physicians and advanced practice providers with the region’s most advanced technology across 13 clinics. Oklahoma Heart Institute offers critical care, interventional cardiology, noninvasive cardiology, electrophysiology, advanced heart failure treatment, and metabolic studies.  Oklahoma Heart Institute is also involved in over 200 cutting edge research studies across the vast amount of specialties within the system.

POSITION SUMMARY 

The Regulatory Compliance Manager is responsible for ensuring that the company is conducting its business in full compliance of with all national and international laws, including regulations that will involve the creation, review and implementation of policies and procedures and best practices within the industry. The Regulatory Compliance Manager applies and interprets audit and compliance requirements for various departments. They interact with external auditors on matters related to audits of the organization’s internal controls, and assess potential fraud activity, plus develop fraud detection tools as well as do any GAP analysis on best practices and make sure that there is a robust risk and compliance framework in the organization.

Facility Compliance Officer Role

• Monitor operational processes and procedures to ensure that the facility complies with all legal regulations and ethical standards
  • Maintain the facility’s compliance work plan using OIG guidance
• Coordinate and monitor the Ardent Code of Conduct and oversee related training which includes New Employee Orientation and annual Code of Conduct
• Monitor adherence to internal controls by proactively conducting internal reviews and audits to ensure all staff are following compliance procedures and to identify potential weaknesses and noncompliance situations within the facility
• Coordinate and conduct internal investigations into compliance issues
  • Conduct and cooperate with investigations
  • Ensure no retaliation for good faith reporting
• Collaborate with external and internal auditors and HR, when needed
  • Coordinate and support corporate monitoring and auditing procedures
  • Review internal audit reports and investigative reports
• Address employee concerns or questions on legal compliance
  • Advise colleagues on ethics and compliance matters
• Coordinate and attend meetings with managers and leadership teams
  • Attend the facility’s clinical ethics committee
• Conduct routine department compliance rounding and report to compliance committee
• Responsible for maintenance of compliance policies in Policy Tech
  • Oversee facility compliance with records retention requirements
• Chair the Facility Compliance Committee
  • Responsible for coordination of Facility Compliance Committee meetings
• Submit quarterly reports to the Market Compliance Officer, as relevant
  • Participate in scheduled market compliance committee meetings

Facility HIPAA Privacy Officer Role

• Monitor operational processes and procedures to ensure that the facility complies with all legal regulations and ethical standards related to HIPAA
• Oversee, direct, deliver or ensures delivery of privacy training and orientation to all employees, volunteers, medical and professional staff and applicable business associates
• Assess facility methods and procedures used to store and transmit PHI; identify security or other compliance risks and recommend improvements
• Address employee concerns or questions on HIPAA compliance
  • Advise colleagues on HIPAA ethics and compliance matters
• Coordinate and conduct internal investigations into HIPAA compliance issues
  • Conduct and cooperate with investigations, internal and external
• Ensure compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the facility’s workforce, extended workforce, and for all business associates in cooperation with his/her supervisor, HR, ISO
• Utilize Ardent platform to document processes for receiving, documenting, tracking, investigating and taking action on all complaints concerning the facility’s privacy policies and procedures
• Perform ongoing privacy risk assessments and audits
  • Monitor Ardent systems designed to track individual’s access to protected health information and investigate as necessary
  • Conduct routine Release of Information audits to monitor vendors performance
  • Ensure Business Associate Agreements are active prior to sharing patient information with a third party
  • Other reviews as assigned
• Conduct routine department HIPAA rounding and report to compliance committee
• Oversee and ensure the right of the facility’s patient to inspect, amend and restrict access to protected health information when appropriate
• Responsible for maintenance of HIPAA policies in Policy Tech
  • Oversee facility compliance with records retention requirements
• Chair the Facility Breach Committee
  • Responsible for coordination of Facility Breach Committee meetings
• Submit quarterly reports to the Market Compliance Officer, as relevant
  • Participate in scheduled market HIPAA committee meetings
• Maintain up-to-date knowledge of federal and state privacy laws and HIPAA regulations
• Cooperate with the U.S. Department of Health and Human Services Office of Civil Rights, other legal entities and organization officers in any compliance reviews or investigations

Required Qualifications

• Bachelor’s degree in healthcare or related field
• 2+ years of experience with compliance or compliance related experience

Preferred Qualifications

• Organizational skills
• Communication and people skills
• Ability to solve complex issues related to COI, coding, billing, Privacy, etc.
• Must be able to assess reporting trends and interpret reports to identify possible areas of non-compliance
• Integrity and ability to function/ remain impartial even during potential adversarial conditions, meet deadlines, etc.
• Knowledge and ability to research the regulatory environment (e.g. CMS, state healthcare regulations, coding, billing manuals, HIPAA, HITECH, OCR, etc.)
• Experience working with Legal, outside agencies to include federal law enforcement and/ or auditing agencies
• Ability to utilize Microsoft Office tools to include Word, Excel, PowerPoint, Teams and Publisher
• CHC or CHPC
• IT knowledge in order to run reports/ research
• Someone comfortable working individually or as part of a team
• Willing to learn RADAR, EthicsPoint, PolicyTech and any other compliance related platform

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