Stanford Health Care Manager, Compliance Program Integrity (40015) in Palo Alto, California

Manager, Compliance Program Integrity (40015)

  • Category:Professional

  • Job Type:Full Time

  • Schedule:Days

  • Facility:Palo Alto

  • Req:40015

Job Description

Job Summary

This paragraph summarizes the general nature, level and purpose of the job.

Manages daily compliance program integrity operational activities, key compliance initiatives, compliance projects and compliance program integrity standard work. Assists in the development and maintenance of a robust compliance program for Stanford Health Care, Stanford Children's Health, University Health Care Alliance and Packard Children's Health Alliance. Responsibilities include overseeing and conducting compliance investigations and providing compliance-related guidance across the enterprise; facilitating and staffing the institutional Committee on Management Controls and Compliance; organizing, facilitating and managing the institutional Enterprise Risk Assessment process and ongoing mitigation plans; identifying, researching and communicating regulatory requirements to key organizational stakeholders, including physicians and senior management; overseeing the Compliance Policy Manual; creating compliance training content and materials; presenting compliance training to various audiences; creating dashboards and reports consistent with Stanford Operating System procedures, such as tracking and trending compliance program activities and developing metric-based standard work measurements and tools; and participating in other compliance program elements for the ongoing demonstration of scrutiny-readiness.

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Specific duties and responsibilities may vary depending on department or program needs without changing the general nature and scope of the job or level of responsibility entailed.

Employees must abide by all Joint Commission requirements including, but not limited to, sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Employees must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions.



Executes world class practices of service and patient care in support of C-I-CARE standards.


Uses C-I-CARE templates and the following components for all communication with patients and staff:

· CONNECT with people by calling them their proper name, or the name they prefer (Mr., Ms., Dr.)

· INTRODUCE yourself and your role

· COMMUNICATE what you are going to do, how long it will take, and how it will impact the patient

· ASK permission before entering a room, examining a patient or undertaking an activity

· RESPOND to patient's questions or requests promptly; anticipate patient needs

· EXIT courteously with an explanation of what will come next.

Contributes to the achievement of Compliance and Privacy Department goals and objectives; adheres to departmental policies, procedures and standards; complies with organizational policies and procedures, governmental laws/regulations and accreditation standards.

Effectively maintains collaborative working relationships to achieve increased satisfaction with and participation in the Compliance and Privacy Program.

Conducts thorough, timely, and fair compliance investigations and assesses the viability and severity of underlying concerns. Assists Compliance and Privacy Department leadership and other appropriate individuals regarding corrective action recommendations concerning non-compliant behaviors; creates complete, accurate, and timely closure documentation of complaints from patients, staff, faculty, and others.

Oversees the management of compliance program integrity guidance processes, including the provision of guidance in the areas of Code of Conduct, visiting observers, administrative educational program site visits, record retention and destruction, conflicts of interest, gifts, and physician arrangements.

Manages intake of and response to calls that come into the institutional hotline, including anonymous calls, and applies institutional non-retaliation policies to protect callers.

Manages preparation for and facilitation of the Committees on Management Controls and Compliance meetings and record keeping; organizes, facilitates and manages the institutional Enterprise Risk Assessment process and ongoing mitigation plans.

Prepares annual and ad hoc reports for the Audit and Compliance Committee of the hospitals' Board of Directors.

Develops and delivers Compliance Program Integrity training; conducts analysis of current state training content and materials and maps to future state training content.

Oversees Compliance Policy Manual and assists in performing ongoing risk assessments of compliance policies and procedures; identifies gaps and makes recommendations to address any gaps, including timeframes and resources; drafts new policies and edits existing policies.

Represents the Compliance and Privacy Department in organizational meetings; serves as compliance subject-matter expert.

Participates in Compliance and Privacy Department improvement projects.

Supports the Chief Compliance and Privacy Officer and other members of Compliance and Privacy Department leadership in responding to corporate responsibility or governmental investigations/reviews.

Produces and maintains Compliance Program activity records, analytical reports and dashboards related to comprehensive Compliance Program activities.

Tracks and tends Compliance Program activities; manages Compliance Program Integrity issues log and departmental dashboards and produces and manages timelines to ensure issue response deadlines are met.

Annually identifies specific needs for self-development and implements a plan to achieve professional growth.

Performs other related job duties and projects as assigned by the Chief Compliance and Privacy Officer and/or the Director of Compliance Program Integrity.


· Reports to the Director of Compliance Program Integrity.

· The position supervises Compliance Specialist positions.

All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status or on the basis of disability.

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Minimum Qualifications

Education: Bachelor's degree in Healthcare or related field, JD or Master's degree preferred.

Experience: Minimum of 5 years of hospital compliance experience with a thorough understanding of compliance regulations and industry practices.

Licenses and Certifications: Certified in Health Care Compliance (CHC) by the Health Care Compliance Association or comparable association, or successful attainment of compliance certification within the first six months of employment.

Knowledge, Skills and Abilities:

Knowledge and understanding of federal and state compliance program requirements.

Knowledge of general computer applications, such as Excel, Access, Word, PowerPoint, and Visio.

Ability to communicate effectively and persuasively, including excellent verbal and written communication skills.

Ability to work effectively with individuals at all levels and varying backgrounds within and outside the organization.

Ability to plan, organize, prioritize multiple tasks and work independently to meet deadlines.

Ability for excellent precision and complex detail.

Ability to analyze and develop solutions to complex problems.

Ability to work effectively both as a team player and a leader.

Ability to apply judgment and make informed decisions.