Director of Compliance

JOB TITLE: Director of Compliance 
FLSA STATUS (Exempt/Non-Exempt): Exempt 
SUPERVISION RECEIVED: Reports to Chief Executive Officer 
SUPERVISION EXERCISED: Compliance Staff, as applicable 

GENERAL STATEMENT OF DUTIES 

Responsible for developing, implementing, overseeing, and continuously evaluating Premier and Philadelphia Hand to Shoulder Center compliance program to promote adherence to applicable federal and state laws, regulations, organizational policies, and healthcare industry standards. Provides leadership and guidance regarding regulatory compliance, HIPAA and patient privacy, OSHA and workplace safety compliance, compliance investigations, auditing and monitoring, education and training, and corrective action activities. Conducts routine compliance site visits and assessments across all locations to identify potential compliance and safety concerns and partners with Operations, Human Resources and other departments to ensure identified issues are appropriately addressed and remediated. 

ESSENTIAL FUNCTIONS 

• Develops, implements, maintains, and oversees Premier and Philadelphia Hand to Shoulder Center compliance program, policies, procedures, and related initiatives.  

• Serves as a primary compliance resource to organizational leadership, physicians/providers, managers, and staff.  

• Monitors applicable federal and state healthcare laws, regulations, and regulatory guidance and assists the organization in implementing necessary changes.  

• Develops and maintains an annual compliance work plan based on organizational risks, regulatory requirements, audit findings, and identified trends.  

• Conducts routine compliance site visits and audits across all locations to evaluate adherence to organizational policies and applicable regulatory requirements.  

• Develops standardized site compliance audit tools and maintains documentation of site visits, findings, corrective actions, and follow-up activities.  

• Oversees organizational OSHA compliance activities and works with operational leadership to promote safe and compliant workplace practices.  

• Conducts and/or coordinates OSHA-related site assessments and monitors compliance with applicable workplace safety requirements, including required postings, safety documentation, training, exposure control practices, and other applicable standards.  

• Partners with Operations and site leadership to identify and correct workplace safety and regulatory deficiencies.  

• Develops corrective action plans for identified compliance deficiencies and monitors completion to ensure appropriate remediation.  

• Oversees HIPAA privacy compliance and provides guidance regarding patient privacy, confidentiality, appropriate access, and disclosure of protected health information.  

• Investigates reported or suspected HIPAA/privacy incidents and coordinates appropriate response, documentation, mitigation, and escalation.  

• Receives, reviews, and investigates compliance concerns reported by employees.  

• Maintains appropriate mechanisms for employees and other individuals to report compliance concerns without fear of retaliation.  

• Conducts or coordinates internal compliance investigations, including gathering documentation, interviewing appropriate individuals, documenting findings, and making recommendations to leadership.  

• Partners with Human Resources on investigations involving compliance concerns.  

• Oversees compliance auditing and monitoring activities and identifies trends, areas of risk, and opportunities for improvement.