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Trinity Health Director Integrity, Compliance, Privacy and Risk Management in Sioux City, Iowa

POSITION PURPOSE Under general direction, is responsible for the design, oversight, implementation and maintenance of the Organizational Integrity, Compliance and Privacy Programs and ensures that MercyOne and its affiliates comply with various laws and regulations pertaining to its business activities and privacy of information. The program includes development and maintenance of systems, policies, and procedures designed to sustain MercyOne and its business partners in fulfilling their legal, professional and ethical responsibilities consistent with the Mission, Vision and Values of MercyOne/Trinity Health. Provides oversight to MercyOne’s network facilities in establishing an effective corporate responsibility program. Oversees the performance of on-site audits and/or reviews quality monitoring performed by the Ministry Organization while serving as a technical resource on assessment, documentation, coding, billing and general compliance questions. This position is also responsible for the oversight, implementation and maintenance of the Risk Management & Patient Safety Program across the entirety of MercyOne Siouxland, with the objectives of minimizing risk to patients, visitors, staff and physicians and reducing potential liability and litigation for MercyOne. Oversees the day-to-day activities related to coordinating insurance coverage, assisting the local claims process, interfacing with outside legal counsel, administering the risk management plan on a day-to-day basis, managing and analyzing risk management data, and directing risk management educational programs. Interfaces with Trinity Health’s Insurance and Risk Management Services department (IRMS) and will coordinate new and existing initiatives with Trinity Health as those initiatives are implemented within MercyOne Siouxland.

Position Title: Director Integrity, Compliance, Privacy and Risk Management

Job Code: 1183

Reports To: VP Quality & Integration

Pay Grade: PG 29

Dept/Clinic: Administration

FLSA: Leadership Exempt

Approved By: Human Resources

Date:July 2019

OSHA: 0 - No Risk

POSITION PURPOSE

Under general direction, is responsible for the design, oversight, implementation and maintenance of the Organizational Integrity, Compliance and Privacy Programs and ensures that MercyOne and its affiliates comply with various laws and regulations pertaining to its business activities and privacy of information. The program includes development and maintenance of systems, policies, and procedures designed to sustain MercyOne and its business partners in fulfilling their legal, professional and ethical responsibilities consistent with the Mission, Vision and Values of MercyOne/Trinity Health. Provides oversight to MercyOne’s network facilities in establishing an effective corporate responsibility program. Oversees the performance of on-site audits and/or reviews quality monitoring performed by the Ministry Organization while serving as a technical resource on assessment, documentation, coding, billing and general compliance questions.

This position is also responsible for the oversight, implementation and maintenance of the Risk Management & Patient Safety Program across the entirety of MercyOne Siouxland, with the objectives of minimizing risk to patients, visitors, staff and physicians and reducing potential liability and litigation for MercyOne. Oversees the day-to-day activities related to coordinating insurance coverage, assisting the local claims process, interfacing with outside legal counsel, administering the risk management plan on a day-to-day basis, managing and analyzing risk management data, and directing risk management educational programs. Interfaces with Trinity Health’s Insurance and Risk Management Services department (IRMS) and will coordinate new and existing initiatives with Trinity Health as those initiatives are implemented within MercyOne Siouxland.

ESSENTIAL JOB FUNCTIONAL COMPETENCIES:

1.

Reflects the skills, knowledge and abilities that individuals use as they serve in the role of a leader. The following provides examples of specific behaviors that correspond with MercyOne and Trinity Health leadership competencies: Defines and shares a strategy and vision. Aligns resources toward achievement of Unified Enterprise Ministry results (UEM). Grows and sustains the UEM. Identifies, leads, embraces change.

2.

Demonstrates the knowledge and skills necessary to provide service/care appropriate to the age of the patients served, in accordance with MercyOne standards.

3.

Chairs the Integrity Operations Committee (IOC), which provides oversight of the day-to-day operations of the Organizational Integrity Program.

4.

Designs, implements and administers a comprehensive, uniform Organizational Integrity Program including Standards of Conduct; policies and procedures addressing areas of compliance risk; employee, governance and business partners education and training programs in risk areas; efforts to monitor activities to assess the effectiveness of the overall program; and ongoing communication of compliance and responsibility issues. Develops and/or gives input to organizational policies and procedures on loss control and patient safety. Incorporates MercyOne Health Services Insurance/Risk Management recommendations when applicable.

5.

Serves as a member and provides regular reports to the Local Integrity Committee (LInC). The Local Integrity Committee provides senior management support and assistance in the design and operation of the Organizational Integrity Program.

6.

Through the IOC, coordinates the Organizational Integrity Program with other organizational departments such as Educational Services, Finance, Human Resources, Mercy Home Care, MercyOne Medical Services, and Mission Services.

7.

Serve as the Section 1557 Coordinator responsible for monitoring and implementing MercyOne's compliance with federal laws prohibiting discrimination in federally funded health care programs, including Section 1557 of the Patient Protection and Affordable Care Act ("ACA"). The major responsibilities are (1) to prevent discrimination against patients, employees and others; and (2) to ensure compliance with all procedures and procedural safeguards required under Section 1557.

8.

Serve as MercyOne's liaison to OCR for issues regarding Section 1557 discrimination generally.

9.

Facilitate the implementation of MercyOne's policies and procedures related to Section 1557, and ensure that they are applied consistently across departments.Coordinate revisions to MercyOne's policies and procedures related to Section 1557, as necessary, to ensure that they are up to date and consistent with current requirements under these laws.

10.

Respond to complaints of Section 1557 discrimination violations. The Coordinator should investigate these concerns, institute corrective actions where appropriate, inform the complainant about MercyOne's complaint procedure and assist individuals in filing complaints when needed.

11.

Assists in the identification of areas requiring ongoing training and education for staff in support of the Organizational Integrity Program. Seeks input from operating units/departments concerning training and education needs in areas of highest risk. Through the IOC, oversees the development and implementation of compliance training and education programs. Develops, coordinates and/or presents education and communication programs for clinical and non-clinical staff related to patient safety and risk management within MercyOne and/or other relevant topics related to the delivery of patient care. Collaborates with MercyOne departments/services to identify relevant patient safety and risk management activities and processes between and across departments.

12.

As appropriate, coordinates the organizations investigative efforts and the resolution of findings related to reported violations of laws, regulations and the Code of Conduct.

13.

Coordinates systems, policies and procedures to periodically measure the effectiveness of the Organizational Integrity Program for evaluation by management and the Finance Committee of the Board of Directors.

14.

Provides supervision to Charge Description Master maintenance and charge capture improvement initiatives.

15.

Corroborates in the completion of annual risk assessments, performance improvement plans, and focused education programs that assist in gaining and maintaining compliance.

16.

Confirms written reports that document findings of reviews and monitoring effects. Reports non-compliance issues detected through reviews and monitoring and the results of follow-up reviews as outlined in the Network facility Corporate Responsibility Program.

17.

Serves as a technical resource for documentation, coding/billing regulations and system interfaces within the MercyOne community.

18.

Assists in the development of and utilizes tools to trend, analyze and interpret changes and variations to identify potential problems and areas requiring focused review.

19.

Is responsible for the coordination of compliance programs for the regional network hospitals and long term care facilities, i.e., providing consultation to the facility compliance officers, committees and local boards; in addition oversees the network compliance hotline for all network facilities.

20.

Implements and ensures ongoing systems to comply with requirements of the Safe Medical Device Act and tracks and/or reports recalls and/or issues associated with the safety of medical devices and products.

21.

Provides oversight to the monitoring and evaluation of departmental risk identification, claim management, and loss control activities. Coordinates follow up of actual/potential adverse occurrences. Reports to corporate risk management representative or insurance claims representative and appropriate department/medical staff committee.

22.

Acts as the MercyOne representative and liaison with local and corporate legal counsel; coordinates schedules for depositions; assists legal counsel in preparing depositions, interrogatories and researching same. Represents MercyOne during trial proceedings related to professional and general liability lawsuits.

23.

Presents and/or reports risk management issues, outcomes and recommendations to Nursing Management, MercyOne Medical Services, Mercy Home Care, administration and the Quality Review Committee of the board.

24.

Leads investigations for adverse drug events and sentinel events.

25.

Participates in corporate risk management education seminars, task forces and improvement activities when the opportunity presents itself.

26.

Evaluates and provides input on contracts and/or agreements developed and/or executed by MercyOne and educational institutions, professional affiliates and other contracted services. Ensures contracts/agreements meet the risk management/insurance coverage requirements. Refers contracts/agreement for review and/or input by corporate staff when appropriate.

27.

Functions as a team member in the patient complaint resolution process by consulting with the Patient Representative, Social Services, Pastoral Care, Patient Accounts and other organizational entities in the resolution of patient complaints.

28.

Functions as, or in conjunction with, the Patient Safety Officer and/or coordinates investigation of potential or actual problems. Coordinates the initial investigation of potential or adverse events, actively participates in the root cause analysis (RCA), and collaborates with the appropriate leadership to establish implementation timelines and monitors the closure of the corrective action plan.

29.

Collaborates with others to develop, modify and create feedback to the organization on a regular basis about the learning's from SRE's, sentinel events, and incident reports.

30.

Implements and ensures ongoing systems to comply with requirements of the Safe Medical Device Act (SMDA) and tracks and/or reports recalls and/or issues associated with the safety of medical devices and products. Works collaboratively with all other hospital departments who have responsibility for SMDA tracking and/or reporting.

31.

Provides guidance and support for patient care issues with legal implications (i.e. consent issues, adoption, guardianship, EMTALA, HIPAA).

32.

Participates in and supports the Risk Management/Patient Safety Committee/Quality Committees.

33.

Is responsible for creating an environment of organizational learning about patient safety and medical/health care error reduction, supports sharing of knowledge, and fosters behavioral changes to improve patient safety.

34.

Knows, understands, incorporates, and demonstrates the MercyOne and Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

35.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, MercyOne and Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

36.

Maintains confidentiality of information pertaining to clients, physicians, employees, and MercyOne business.

37.

Demonstrates general working knowledge of computers and department specific software (i.e. Healthstream, internet, etc.)

38.

Performs other duties and responsibilities as assigned.

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.

Our Vision

MercyOne will set the standard for a personalized and radically convenient system of health services.

— — —

Our Values

Integrity – We are faithful to who we say we are.

Commitment to the Poor – We stand with and serve those who are poor, especially the most vulnerable.

Compassion – Solidarity with one another, capacity to enter into another’s joy and sorrow.

Excellence – Preeminent performance, becoming the benchmark, putting forth our personal and professional best.

Justice –We foster right relationships to promote the common good, including sustainability of the Earth.

Stewardship – We honor our heritage and hold ourselves accountable for the human, financial and natural resources entrusted to our care.

Reverence – We honor the sacredness and dignity of every person.

— — —

Our Cultural Beliefs

Be ONE

I benefit from and strengthen MercyOne.

Personalize Care

Your experience. My responsibility.

Own It!

I own my actions to deliver our key results.

Improve Daily

I make improvements every day for those we serve including each other.

Innovate

I imagine and embrace bold new ideas to revolutionize health.

COMMITMENT

Must be able to embrace and adhere to the Guiding Behaviors of the organization and support the Mission of Trinity Health. Must demonstrate good work habits such as time management, attendance, punctuality, team building and other behaviors aligned to the Guiding Behaviors of the organization.

MINIMUM QUALIFICATIONS

Requires a Master's degree in Nursing, Business Administration, Law, Quality or Risk Management or other related field. Must hold a nursing license. Requires certification in Health Care Risk Management. Within one year of employment, must attain certification in Healthcare Compliance and Privacy (HCC). Requires a minimum of 5-7 years of related experience in an acute care setting. Must demonstrate working knowledge of relevant Federal, State, Joint Commission and other external agency regulations and requirements in the areas of responsibility required. Must possess analytical and problem-solving skills necessary to develop and implement policies, procedures, budgets and prepare special reports and analyses. Must be comfortable operating in a collaborative, shared leadership environment. Must be able to cope effectively with stressful situations and time constraints. Human relation and communication skills needed to maintain rapport and working relationships with medical staff, administration, department personnel, external agencies, patients and their families. Must have good negotiation, consensus building and presentation skills. Must have general working knowledge of computers and department specific software (i.e. word, excel, bed tracking, internet, med aide, etc.) Required to travel within the Siouxland region in order to perform job duties and responsibilities as assigned. A valid driver's license and proof of insurance must be submitted by the employee to their manager and will be maintained throughout employment. Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of MercyOne and Trinity Health. Must have ability to organize work, is detail oriented and thorough. Must be self-directed, able to work and make decisions independently. Successful individual should be a mature executive with a professional appearance/demeanor, excellent character, integrity and commitment.

MercyOne cultivates, upholds and supports a safe work environment. Associates support patient and staff safety by demonstrating aptitude and maintaining organizational employment standards and requirements. Associate job performance is continually appraised and formally evaluated during the course of employment with MercyOne.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

Must successfully pass employment physical examination and must adhere to applicable organizational requirements on an annual basis for Employee Health Directives. Must possess the ability to comply with MercyOne and Trinity Health policies and procedures. This job is categorized as "Light Work". Has the physical stamina to meet the requirements of this job. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently. Involves sitting most of the time, but may involve walking or standing. Must be able to handle stress effectively. Must understand and accept the possibility of exposure to environmental elements, internal and external, which may affect the work place, such as infectious disease, chemical and/or chemical fumes, dust, noise, physical injury from an out of control patient, and adverse effects of inclement weather which may occur.

These essential functions identify the major requirements of the job. They are not an exhaustive list of all job requirements. An employee may be called upon to perform physical actions not specifically identified in this job description.

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Job Number: 00165096

Location: Sioux City, IA

Organization Name: MercyOne - Sioux City

Facility: MMCIA - MMC Central Building

Employment Type: Full time

Shift: Day Shift

Hours: 40

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