Director, Compliance

Summary

The Director develops and oversees execution of annual compliance work plans, assesses the effectiveness of internal controls and compliance processes, oversees compliance monitoring activities, and provides timely reporting of significant risks, corrective action plans, and emerging regulatory issues to executive leadership and the Board of Directors Compliance Oversight Committee. The role serves as a strategic advisor to leadership.

• GENERAL SUMMARY
• The Director, Compliance provides independent, objective leadership and oversight of the health system's compliance function. This role is responsible for developing, implementing, and maintaining a comprehensive compliance program designed to evaluate and strengthen governance, risk management, regulatory compliance, internal controls, operational effectiveness, financial stewardship, and organizational integrity.
  

The Director collaborates closely with Legal, Finance, Revenue Cycle, Human Resources, Information Security, Privacy, Clinical Operations, and other business leaders to identify, assess, monitor, and mitigate operational, financial, regulatory, privacy, cybersecurity, and enterprise risks.

Reports administratively to the President/CEO and maintains direct reporting access to the Chair of the Board Compliance Oversight Committee. This reporting relationship supports the independence and objectivity required for effective compliance oversight.

• ESSENTIAL DUTIES AND RESPONSIBILITIES
• Compliance Program Oversight
• Monitors trends, emerging risks, and industry developments impacting healthcare compliance.
• Supports the design, implementation, and continuous improvement of the health system's compliance program.
• Evaluates and monitors compliance program effectiveness across all areas of the organization.
• Oversees compliance auditing and monitoring activities related to federal and state healthcare regulations, payer requirements, organizational policies, and other applicable laws.
• Oversees follow-up reviews and/or compliance monitoring to ensure timely implementation and sustained effectiveness of corrective action plans.
• Works collaboratively with the Legal department and operational leaders to address and mitigate compliance risks.
• Facilitates compliance education, awareness, and communication initiatives that promote ethical business conduct and regulatory compliance.
• Supports the review, investigation, documentation, and resolution of compliance concerns and reported allegations of misconduct, as appropriate.
• Monitors emerging healthcare regulatory requirements and collaborated with leadership to assess organizational implications.
• Identified opportunities for process improvement and control performance.
• Serves as a trusted advisor to leadership on compliance practices.
• Serves as HIPAA Privacy Officer for CHKDHS with in-depth knowledge of HIPAA Privacy, Security, and Breach Notification standards and oversight of related investigations and activities.
• Promotes a culture of ethics, accountability, transparency, and continuous improvement throughout the organization.
• Executive and Board Reporting
• Provides routine and ad hoc reports to executive leadership and the Board Compliance Oversight Committee regarding compliance audits and compliance work plan execution, significant findings, compliance program performance, regulatory developments, corrective action status, and emerging risk trends.
• Escalates significant compliance concerns, control deficiencies, fraud risks, and other high-risk matters requiring immediate executive or Board attention.
• Technology, Privacy, and Cyber Risk Oversight
• Collaborates with Information Security, Information Technology, Privacy, Legal, and business leaders to evaluate technology, cybersecurity, privacy, data governance, and system-access risks.
• Supports planning and actively participates in exercises that assess controls related to electronic health records, financial systems, data integrity, cybersecurity, third-party technology vendors, and digital operations.
• Supports enterprise initiatives involving emerging technologies and automation by evaluating associated compliance and control risks.
• Leadership
• Provides strategic leadership and direction for the Compliance and Internal Audit Department.
• Recruits, develops, coaches, mentors, and evaluates staff to achieve departmental and organizational goals.
• Establishes departmental objectives annual enterprise-wide compliance work plan, performance expectations, succession plans, and professional development initiatives.
• Fosters a culture of collaboration, accountability, innovation, integrity, service excellence, and continuous improvement.
• Manages departmental budgets, resources, and operational priorities to ensure effective utilization and achievement of strategic objectives.
• Leads, manages, coaches, and trains a team or department, provides guidance, support, and mentors to ensure optimal performance and productivity.
• Oversees the recruitment, hiring, team/department orientation, performance appraisals and disciplinary actions including up-to -termination processes for a team or department.
• Performs additional responsibilities as assigned by the President/CEO, Board Compliance Oversight Committee, or designated leadership.
• LICENSES AND/OR CERTIFICATIONS
• Required Licenses and/or Certifications
• None required.
• MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
• Required and Preferred Education and Experience
• Bachelor’s degree in Accounting, Business Administration, or other relevant field strongly preferred.
• 7 years of progressively responsible experience in healthcare compliance, accounting, risk management, regulatory oversight, public accounting, internal audit, or a related field required.
• 3 years of leadership or management experience required.
• One of the following professional degrees or certifications preferred: Certified Public Accountant (CPA), Certified Internal Auditor (CIA), Juris Doctorate (JD), or an equivalent professional certification directly related to accounting, compliance, or risk management preferred.
• Experience presenting findings and recommendations to senior executives and governing boards required.
• Experience within a complex healthcare system, academic medical center, integrated delivery network, or similarly regulated environment preferred.
• Experience leading enterprise-wide compliance, audit, or risk management initiatives preferred.
• Required Knowledge, Skills and Abilities
• Advanced knowledge of healthcare regulatory requirements, internal controls, auditing practices, compliance program frameworks, governance principles, and risk management methodologies.
• Strong understanding of healthcare reimbursement, revenue cycle operations, financial reporting, and operational risk management.
• Knowledge of applicable federal and state healthcare laws, regulations, and compliance expectations.
• Exceptional analytical, critical thinking, investigation, and problem-solving skills.
• Strong project management, organizational, and strategic planning skills.
• Proficiency with data analytics, auditing technologies, Microsoft Office applications, and enterprise business systems.
• Demonstrated ability to build credibility, collaborate effectively, and influence across all levels of the organization.
• Excellent written, verbal, presentation, and executive communication abilities.
• Ability to communicate complex risks and findings to executive leaders and governing boards.
• High level of integrity, discretion, objectivity, confidentiality, independence, and professional judgment.
• WORKING CONDITIONS
• Normal office environment with occasional travel throughout health system facilities. May require attendance at meetings outside normal business hours as necessary to support Board, Audit Committee, regulatory, or organizational needs.
• PHYSICAL REQUIREMENTS
• Click here to view physical requirements.