Director - Hospital Compliance

Beth Israel Deaconess Medical Center

Job Description

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Director - Hospital Compliance

Department Description:We are seeking two individuals to support our Compliance Department.

The one role will be the Director of Compliance Hospital Operations providing direction to Anna Jacques and Beverly Hospitals.

The other role will be the Director of Compliance Hospital Operations providing direction for Milton and Needham Hospitals.

Job Location:Boston, MA

Req ID:35065BR

Job Summary:Reporting directly to the System Compliance Officer and designee for Beth Israel Lahey Health System, the Director, Hospital Compliance is responsible for leading the Compliance Programs for Beth Israel Deaconess Hospital Milton and Beth Israel Deaconess Hospital Needham or service lines assigned, and for ensuring effective oversight and management of compliance operations. The Director serves as the entities' or service lines Compliance Officer working within an enterprise-wide centralized compliance function. The Director supports BILH system initiatives, including routine and ad hoc reporting for Board purposes, serves as subject matter expert and supports cross-functional coverage of issues and inquiries as needed, and participates as an effective team member and leader on various BILH compliance system-related initiatives.

Essential Responsibilities:

  • Develops and maintains a compliance program designed to ensure compliance with applicable privacy standards and regulations such as HIPAA, HITECH, and various state laws; applicable government payor requirements such as Medicare and MassHealth, and other essential state and federal laws, rules and regulations.

  • Plans, executes, and manages investigations, engaging other BILH Compliance subject matter experts and consulting with legal counsel as needed to effectively manage timely and thorough reviews.

  • Develops corrective actions together with operations and other leaders, monitors implementation and provides periodic status updates and recommendations as needed.

  • Works with stakeholders to identify and mitigate risk and potential areas of non-compliance, actively participates in annual risk assessment and other related initiatives.

  • Leads the Compliance Committee for the assigned entity or service line, ensuring stakeholder engagement, regular meetings, appropriate documentation, the discussion of relevant compliance activities, and escalation of key matters as needed and per protocol.

  • Ensures effective tracking of reports, timely follow-up and investigation. Provides routine updates on progress, and/or corrective action when deficiencies are identified.

  • Provides input into various BILH Compliance Operations initiatives such as annual and new hire compliance training and/or other compliance integration efforts.

  • Stays informed of new and emerging areas of compliance and privacy risks, trends and/or best practices relevant to the compliance and privacy program; shares information with other Compliance Department members and organizational staff as appropriate.

  • Coordinates and/or responds to requests from BILH Compliance Leadership which may include board report preparation, review and investigation of select topics, audit requests, periodic surveys, serving on ad hoc committees, assisting with the annual Work Plan, education and training and other initiatives, etc.

  • Has the responsibility to lead and support managers and directors in developing and improving operations to create optimal performance levels. Direct Reports: None Indirect Reports: None

Required Qualifications:

  • Bachelor's degree in Healthcare, Business, Law required. Master's degree preferred.

  • License Cert. in Healthcare Compliance required.

  • 5-8 years related work experience required in Healthcare Compliance and Privacy and 0-1 years supervisory/management experience required

  • Five years of escalating responsibility and work-experience in compliance and/or privacy field (healthcare, law, internal audit) including progressive program and project management roles in large and complex organization.

  • Knowledge of pertinent compliance and privacy regulatory requirements and compliance program elements including demonstrated understanding of OIG Compliance Guidelines, billing compliance principles, and HIPAA Privacy requirements in a hospital setting or other setting relevant to site or service line assignment.

  • Ability to communicate, collaborate and work effectively with senior leadership, as well as all levels of an organization including management, leadership, and line staff across range of functional areas.

  • Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.

Preferred Qualifications:

  • Prior health care compliance and privacy experience in similar setting.

  • Excellent Research Skills.


  • Decision Making:Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

  • Problem Solving:Ability to address problems that are broad, complex and abstract, often involving Medical Center-wide issues and requiring substantial creativity, resourcefulness, staff engagement, Lean diagnostic techniques, negotiation and diplomacy to develop solutions.

  • Independence of Action:Ability to set goals and priorities for functional area. May make recommendations for department policies, practices and programs. Manager or Director provides broad guidance and overall direction.

  • Written Communications:Ability to communicate complex information in English effectively in writing to all levels of staff, management and external customers across functional areas.

  • Oral Communications:Ability to verbally communicate complex concepts in English and address sensitive situations, resolve conflicts, negotiate, motivate and persuade others.

  • Knowledge:Ability to demonstrate broad and comprehensive knowledge of theories, concepts, practices and policies with the ability to use them in complex and/or unprecedented situations across multiple functional areas.

  • Team Work:Ability to lead collaborative teams for larger projects or groups both internal and external to the Medical Center and across functional areas. Results have implications for the management and operations of multiple areas of the organization.

  • Customer Service:Ability to lead operational initiatives to meet or exceed customer service standards and expectations in assigned unit(s) and/or across multiple areas in a timely and respectful manner.

Physical Nature of the Job:

Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

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