Serving People, Saving Lives!

BrightView was founded to give the people in our communities two things: help and hope. If you want to do the same, we would love for you to join our dynamic, rapidly growing organization and help us make a difference in hundreds of lives every single day.

Position Summary:
This leadership position will oversee all aspects of licensure, accreditation, and compliance. This leadership position provides consultation to the organization and manages accreditation readiness through participation in operational committees, communication, facilitation, and audit programs. This role will ensure that BrightView adheres to all laws, regulations, policies, and procedures. The Director will anticipate and aggressively manage operational and compliance risks; and ensure the integrity of the organization’s internal controls; and ensure strong stewardship and accountability at all levels.
Essential Job Duties:
Works in conjunction with the Vice President of Regulatory Affairs, organizational leaders, site level leaders, medical staff, and allied health staff to collect, analyze, and report data related to the BrightView Compliance and Privacy Program Plan.
Maintains current knowledge and interprets requirements related to The Joint Commission, Drug Enforcement Agency, and all other regulatory bodies.
Serves as the Privacy officer for multiple locations, and ensures adherence to the required HIPAA, 42 C.F.R. Part 2, and documentation requirements as identified by county, state, and federal regulatory agencies.
Takes a lead role to ensure the organization has and maintains appropriate privacy and confidentiality consents, authorization forms and information notices and materials reflecting current organization and legal practices and requirements.
Assists in the management of all on-site survey activity from accrediting/licensing and other regulatory bodies.
Manages breach determination and notification processes under HIPAA and applicable State breach rules and requirements
Performs or oversees initial and periodic information privacy risk assessment/analysis, mitigation and remediation.
Creates and monitors Business Associate Agreements to ensure that all Business Associates are maintaining privacy requirements and responsibilities.
Cooperates with the U.S. Department of Health and Human Service's Office for Civil Rights, State regulators and/or other legal entities, including outside counsel, in any compliance reviews or investigations.
Serves as information privacy resource to the organization regarding release of information and to all departments for privacy related issues.
Co-Chairs the Compliance Committee to review compliance topics with organizational leadership.
Manages responses to subpoenas to ensure compliance with 42 C.F.R. Part 2.
Conduct operational and compliance audits that are significantly complex in nature and involve complex and ambiguous laws, regulations, and fraud investigations.
Conduct research and develop audit programs and testing to determine whether audit goals and objectives are achieved.
Verify compliance by reviewing applicable laws, regulations, policies, procedures, and internal controls. Coordinate with other state and/or local government agencies, as require
Lead contact for all external/ third party audit activities.
Proactively assesses risks and executes the audit plan, resulting in timely audit deliverables, resolving and communicating issues or problems in an appropriate manner.
Creates clear and accurate audit findings and recommendations in written audit reports that will be used for advising and stakeholders throughout the organization.
Leads the development of compliance-related dashboards intended to inform our audits and serve as a resource for the organization.
Facilitates, develops, and implements special projects as assigned by the VP of Regulatory Affairs and senior leadership
Performs all other administrative and supervisory duties as assigned.
Required Travel:

45%
Travel to other locations for audits, training's and meetings.
Required Education/Degree:
Bachelor’s degree Preferred.
Required Work Experience:
Four or more years of healthcare experience with Joint Commission Accreditation and DEA compliance.
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.