There are many ways to define excellence. For us at The Christ Hospital, it’s all about our patients…And making healthcare what they want it to be. Accessible. Personal. Affordable.
Our commitment to exceptional outcomes, affordable care and the finest patient experiences is recognized yearly with numerous awards from leading healthcare organizations and publications. At the top of our list of honors are the 17 consecutive years that we’ve been named to U.S. News & World Report’s list of Best Hospitals and being named the Most Preferred Hospital by the Greater Cincinnati community for 21 consecutive years (National Research Corporation).
What does this mean for you?
GROWTH- opportunities to learn, develop, and impact.
VALUE- a robust employee package that provides you the ability to maintain a healthy work-life balance, competitive compensation, flexible and meaningful benefits, development opportunities so you can be your best self, and a culture of compassion.
PRIDE- from all that we have accomplished in our past, and all that we’re positioned for in the future.
CHALLENGE- we are in one of the most competitive markets in the nation, yet continue to rise to the top through our incredible employees and transformational results. We seek individuals motivated by what it takes to be a part of a winning team.
Named #24 on Forbes 500 America’s Best Employers for 2017, we are transforming care…inspired by you.
Title: System Director of Audit, Compliance and Organizational Ethics
Shift: Full-Time, Days
This position will be located in the Compliance Department at The Christ Hospital, 2139 Auburn Avenue, Cincinnati, Ohio 45219.
Job Overview: The System Director of Audit-Compliance and Organizational Ethics (Director) oversees related audit, monitoring, policy development, education and training, and compliance and internal audit risk assessment and reporting functions for the system. The Director works in conjunction with the Chief Risk Officer (CRO), and the Chief Compliance Officer (CCO), Counsel, and System Security Officer in assuring coordinated audits and risk assessments of TCH system processes are performed. The Director participates with the CRO and the CCO in planning and executing specialized training and education for the system, and is responsible to design audit systems, and oversee the effective execution of audits and management action plan-monitors as required. The Director-Audit serves as an integral liaison and resource to System Management, employees, Physicians, external stakeholders in auditing, action planning and consulting related to the Compliance and Organizational Ethics Program and Enterprise Risk Management mitigation.
The System Director of Audit-Compliance and Organizational Ethics may perform the following duties:
- Oversees auditors in the planning and execution of the annual work plans and risk assessments. Assures audit processes are in comportment with generally accepted auditing standards, including risk assessment methods
- oversees and develops data base tools to track progress and monitor effectiveness. Develops e monitoring and other audits in comportment with regulatory and department compliance policy requirements. Maintains depth in audit principles and functions independently, exercising sound judgment to recognize potential instances of non-compliance and when legal counsel may need to be consulted. Maintains superior skills in Excel.
- Responsible for executing processes that effectively validate and monitor management’s comportment with recommendations. Develops data bases to track remuneration, BAA’s, hotline calls and other domains subject to data basing. Oversees audit function that monitor remuneration and contracts. Assists CCO and/or Counsel with contract reviews to assure all required compliance elements are present
- develops audit report process and content, oversees auditor in the preparation of reports to management with findings
- oversees the tracking of action plan responses and assures management develops effectiveness measures. Consults as needed with the Chief Compliance and/or Chief Risk Officer in development of measures. Assures maintenance and efficient operation of a centralized non-monetary compensation database. Recognizes and responds appropriately to suspected non-compliance and management requests for audit services.
- Assures robust data bases are maintained to assure tracking of training, remuneration, audits and risk assessments are coordinated and logged. Develops interventions to assure all mandatory annual training is timely completed. Performs on boarding and physician –employee training as needed and develops adjunct training materials to support training and education. Maintains proficiency in knowing what data should be dash boarded, and prepares dashboard reports and effectiveness reports. Consults with management on dashboard reporting and effectiveness assessment and establishes a regular, helpful, non-punitive and consultative presence with management.
- Assures adequate data, testing files are maintained, advises auditors in the preparation of reports
- proficient in QA’ing reports for accuracy, diction, relevance. Functions independently to assure audit functions are effective. Assures corrective actions and recommendations are tracked for effectiveness follow up. Meets with Management and physicians and at times the Board on audits and activities, or to give advice. Consults counsel and/or legal when privilege may need to be invoked. Is knowledgeable of regulations, and able to determine when non-compliance may be evident. Independently directs Management in corrective measures. Maintains pristine and retrievable records of actions and reports.
- Directs the process to manage the HIPAA privacy data bases and behavioral monitoring tool. Assures sufficient coverage in the dept. for investigating privacy reports, and for monitoring audit tool results/including follow up.
- Directs the HIPAA privacy program, acting as the Privacy Officer as delegated. Oversees privacy investigations, and applies appropriate OCR standards for risk assessment and timely reporting. Assures annual HIPAA security audit is performed, data based and reported to management.
- Maintains at least one Internal Audit Certification, and maintains an excellent working knowledge of the interactions of process and concordant auditing standards and methods.
- Works collaboratively with the Director Compliance –Privacy Officer, CCO, Legal and Senior Management on compliance and audit matters. Covers Department oversight in the absence of the Director/CCO.
Education: Minimum Required: Bachelor’s Degree in Accounting or Finance with a CPA and Internal Audit Certification or equivalent.
License & Certification: CPA, or equivalent is required, Certification in Health Care Compliance (CHC) or equivalent Internal Audit Certification after 24 months on the job.
Years of Experience: Five (5) years of progressively responsible professional work experience including exposure to executives, boards, and regulatory requirements. Healthcare experience of 5 years or equivalent experience in a regulated environment (such as banking-health care preferred) is required.
Required Skills & Knowledge: Possesses general healthcare compliance knowledge. CPA or other advanced audit certification is required. Critical and/analytical thinking skills, understanding risk and risk assessment/mitigation techniques is essential.
Must possess strong and advanced knowledge of Microsoft Excel to oversee audit and data bases.
Working knowledge of Microsoft Office and Access. Strong organizational and communication skills, both oral and written. Must be able to communicate well with a wide variety of audiences and possess excellent critical thinking and problem solving skills. Ability and willingness to confront issues and negotiate. Must have the ability to work effectively independently, under pressure and with strict deadlines. Advanced knowledge of audit techniques and report writing. The ability to influence others and exercise commensurate independent judgment and discretion in areas of responsibility is required along with the ability to accomplish multiple tasks simultaneously and initiate corrective measures, when indicated, autonomously. Ability to analyze complex issues, identify problems and solutions. Proven ability to develop and implement innovative methods designed to improve service. Excellent teaching mentoring, and presentation/public speaking skills.
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