Director, Educational Compliance

POSITION SUMMARY

The Director of Educational Compliance is responsible to ensure that the institution and its accredited programs adhere to the rigorous institutional and program standards and requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME), Health Resources and Services Administration (HRSA), Center for Medicare and Medicaid Services (CMS), the Commission on Osteopathic College Accreditation (COCA), the Commission on Dental Accreditation (CODA), and the Liaison Committee on Medical Education (LCME). The Director of Educational Clinical Compliance works closely with Graduate Medical Education (GME) and the educational leadership and staff to identify and address potential compliance issues, and routinely validates audits and investigations to ensure the organization is meeting all compliance, policy and procedure requirements. 

REPORTING RELATIONSHIPS

This position will report to the Vice President and Chief Compliance Officer.  No staff report to this position.

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Director of Educational Compliance will:

• Promote the mission, vision, and values of the organization and act as an ambassador for our mission internally and externally 
• Provide consulting to staff and leadership on educational and compliance best practices and methods
• Conduct risk assessments and identify potential compliance issues related to  applicable standards, policies, procedures, laws, rules, regulations and accreditation requirements for all educational accrediting agencies as applicable to TWCGME
• Conduct compliance reviews of all clinical learning environments each year as they relate to ACGME requirements and program compliance
• Assist the GME department in resolving compliance issues by providing individual technical assistance, introducing tools and participating in reviews
• Ensure compliance of  the 360°resident/fellow evaluations and timely submission by all stakeholders with regular reports to executive management 
• Ensure compliance with training requirements and expectations, including contract deliverables
• Provide training and education on compliance topics related to graduate medical education and academic affairs
• Ensure that educational compliance metrics are monitored, tracked and reported to the DIO, Program Directors and educational leadership in accordance with the  policies and procedures
• Prepare and present reports on educational compliance activities and necessary improvements to staff, executive management, and governance quarterly and more often as requested
• Oversee compliance tracking and reporting related to regulatory agency requirements 
• Actively participate in GME weekly Level 10 and huddles, clinical operations Level 10, compliance Level 10 and other meetings as necessary
• Prepare and present 5 to 10 minute compliance education on varying topics at the GME level 10 meetings
• Develop a slide presentation for GME Board meetings on compliance education and compliance update
• Lead the development, implement and auditing of the Educational components of the Compliance Program in accordance with accreditation standards such as ACGME, CMS and HRSA guidelines and other applicable regulatory agencies
• Ensure compliance with all GME policies including the development, review and revision of those policies as they relate to the Sponsoring Institution and all programs accredited by the ACGME
• Ensure regular auditing of the GME policies as they relate to the Sponsoring Institution and all programs accredited by the ACGME
• Ensure that standard operating procedures for GME are created and implemented 
• Perform quarterly audits with the credentialing department to ensure all residents/fellows are current with certifications and licensure in accordance with local, state and federal regulations 
• Upon request from senior leadership, assume direct leadership oversight to ensure that all identified compliance issues are remediated and addressed, and that any GME policies or procedures that executive management or the Chief Compliance Officer believe is in need of attention in order to meet ACGME and other agency compliance obligations
• Monitor and report investigations and outcomes of SAFE reports as they relate to GME, academic affairs, and learning environments
• Review and re-assess improvements made as a result of compliance interventions and SAFE reports, PDSAs and root cause analyses
• Ensure compliance with the ACGME Sponsoring Institutional Requirements and to ensure that each of the ACGME accredited programs are in compliance with the ACGME Institutional, Common and specialty/subspecialty - specific Program and Recognition requirements by performing Compliance Risk Assessments and Management with periodic internal and external audits including but not limited to: 
  • Ensuring written policies and procedures are created, reviewed and revised as they relate to topics such as resident and fellow appointments, promotion, appointment/contract, renewal and dismissal, grievances, professional liability, health and disability insurance, PTO and leave of absence, resident services to include access to behavioral health services, physician impairment, harassment, accommodation for disabilities and discrimination, supervision, clinical and educational work hours, vendor interactions, non competition, substantial disruptions in patient care or education, closures and reductions; 
  • Ensuring compliance with the Clinical Learning Environment Review Program;
  • Ensuring regular and effective compliance education and training, related to ACGME requirements and compliance expectation is provided and documented for all employees, and learners;  
  • Investigating and documenting any violations of compliance policies, regulations, or statutes promptly with reporting to the VP Chief Compliance Officer and the Office of the DIO;
  • Ensuring there are processes and consequences in place for residents, fellows and learners who fail to meet compliance standards of conduct, policies, and procedures. This should follow the employee discipline policy process in consultation with Human Resources or for students of other educational institutions,collaboration with that institution;
  • Developing and ensuring compliance with risk assessments of the educational requirements program and identifying trends to reduce the risk and by detecting deficiencies to prevent loss or future loss;
  • Validating that corrective action plan(s) are implemented to minimize risk to the programs; and
  • Ensuring effective interviews of stakeholders and reporting findings as well as next steps.
• As the Title IX Coordinator, ensures all policies the organization's compliance with Title IX of the Education Amendments of 1972, which prohibits sex-based discrimination in any education program or activity receiving federal financial assistance. This role involves overseeing all aspects of the organization's response to reports of sexual harassment, sexual assault, and other forms of sex-based discrimination. Responsible for managing and enforcing policies, oversees investigations, and coordinates training and prevention efforts to ensure a fair and safe environment for all employees, patients, and affiliates. The coordinator also serves as a central resource, providing guidance and support to individuals and departments regarding their rights and responsibilities under Title IX.

LEADERSHIP AND COMPLIANCE 

• Ability to work closely with the Designated Institutional Official, and Vice President of Academic Affairs and Associate Designated Institutional Official, and the GME/Academic Affairs staff on compliance related issues
• Responsible for exercising all applicable protected health information privacy and confidentiality laws, rules, regulations and security measures at all times during office hours and outside the office
• Responsible for demonstrating self-learning through participation in continuing education activities and conferences
• Provide updates, recommendations and policy changes to the GMEC and its subcommittees and to the executive management team and governing boards as needed
• Participate in performance improvement activities

REQUIRED QUALIFICATIONS:

• Meet The Wright Center for Community Health and its affiliated Enterprise entities’ EOS People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• At least a Bachelor’s Degree in Business, Healthcare Administration or similar field.
• 7+ years experience in a healthcare or educational compliance role
• Compliance certification a plus
• In-depth knowledge and experience with education, especially the ACGME, CMS 
• HRSA, CODA and LCME 
• In-depth knowledge of local, federal and state healthcare laws, rules, and regulations
• Strong analytical and problem-solving skills
• Attention to detail and organizational abilities in order to prioritize overlapping and/or conflicting requests 
• Previous experience with an electronic health record preferred
• Proficiency in Google and Microsoft platforms, programs and processes
• Effective communication and interpersonal skills
• Maintain positive, professional office relationships
• Ability to work independently or with a team
• Strong leadership skills in order to influence organizational culture and behavior
• Demonstrate responsibility for personal work habits and self-care
• Maintain patient and employee confidentiality and professional standards as established by applicable laws, rules, regulations and internal policies and procedures
• Ability to handle multiple deadlines and to work in a busy, very dynamic environment
• Ability to provide opportunities and resources to enable employees to successfully perform