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Vice President, Audit and Compliance Services

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Professional/Management
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1800021D Requisition #
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     Reports to the Chief Operating Officer with functional reporting to Dartmouth-Hitchcock-Health (D-HH) and Dartmouth-Hitchcock (D-H) Audit and Compliance Committee of the Board of Trustees regarding all internal audit and compliance program activities including Research Compliance, as well as Population Health.   Partners with Medical Directors in each area of administration, specifically shares Administrative Compliance Officer responsibilities with the Medical Director of Organizational Compliance, leads the D-HH/D-H Management Compliance Committee along with Co-Chairs of the Organizational Ethics Committee who retain program responsibility and subject matter expertise over the respective division/departments.  Works collaboratively with the HIPAA Privacy and Security Officer.
     Provides direct audit and compliance leadership and oversight to the Directors supporting D-HH, D-H Audit and Compliance Services, and the Office of Policy Support.  Overall responsibility for execution of operations and to achieve all goals and objectives including metrics, productivity, financial management, and professional development. Works closely with the Operations, Finance and Quality VPs.
     Aligns and organizes all operations to meet D-HH and D-H existing and future objectives to achieve a sustainable health system while improving the patient experience. All activities must achieve the objective of well-controlled, compliant operations which support accreditation requirements and all applicable regulatory compliance activities. The scope of this position includes D-HH responsibilities delegated to Dartmouth-Hitchcock, as well as affiliates and subsidiaries in accordance with shared service responsibilities. All areas of responsibility must be appropriately coordinated with Dartmouth College for activities, managed by both organizations, e.g. research compliance, College-employed physicians or medical students who are appointed or covered by the D-H Code of Ethical Conduct.
     Fulfills the responsibilities of the D-H Trustee-appointed positions of D-HH and D-H Administrative Compliance Officer and for assigned system members and Next Generation ACO Co-Compliance Officer, as well as D-HH and D-H Internal Auditor.   Acts as the Chief Audit Executive. 
 
Responsibilities:
  1. Provides oversight or direct management activities to meet all performance expectations, including budgets and productivity measures, across all divisions, departments and program objectives under the assigned portfolio.
  2. Develops and implements a comprehensive program with elements of centrally managed and decentralized functions which ensures compliance with all regulatory and accreditation requirements for all programs under management and coordination with other regulatory programs at D-HH and D-H.
  3. Understands and assesses operations, data analysis and operations of systems that support all functions under portfolio.  Understands and assesses accreditation, compliance and internal control risk. Develop and support a shared services model to align system support and reduce/eliminate redundant activities.
  4. Assures appropriate matrixed relationships to ensure all regulatory compliance processes are mutually supportive in ways that promote accreditation and regulatory compliance within a framework of internal controls.
  5. Develops and executes Board approved annual plans that assess risk, specifically for Audit and Compliance Services, and supports reporting for other areas of responsibility. Identifies opportunities to improve operations, reduce risk, and maintain the reputation of D-HH and D-H.
  6. Evaluates and enhances the adequacy and program effectiveness implementation of internal control. Partners with departments, such as Graduate Medical Education, Laboratory Services, and Pharmacy to ensure compliance with applicable accreditation and regulatory requirements. Continually evaluates the reliability and integrity of financial and operational systems, policies and activities.
  7. Provides counsel and advice to management, clinicians, independent auditors, legal counsel and the D-HH Trustees Audit and Compliance Committee to assure that control of risks appropriate for business conditions is effective and efficient.  Advocates for change and functions as a change agent.
  8. Works with executive and senior leadership in an advisory role and develops strong lines of communication and working relationships with management and physician leadership.
  9. Provides direction regarding training, monitoring and auditing to management, physician leadership of divisions, sections and departments specifically related to regulatory compliance functions.
  10. Monitors developments and changes in laws and regulations which may affect the D-H Corporate Compliance Program and Next Generation ACO programs, including compliance with the OIG Compliance Program guidance. Provide Medical Directors/Directors and Senior Managers with necessary guidance, consultation and resources to interpret and achieve compliance with all accreditation programs and regulatory compliance activities.
  11. Provides direct management and/or oversight to ensure the appropriate Committee structures are in place and the Committees are working effectively to meet all best practices and regulatory requirements.
  12. Assure division/departmental staffing and performance meets applicable professional standards.  Maintain and promote division/departmental professional and technical competence through professional development and continuing education.
  13. Function in shared services model with system members, serving as co-compliance leader with aligned organizations under D-HH.
  14. Staffs the Audit and Compliance Committee of the D-HH/D-H Board, preparing agendas, minutes and coordinating agenda, education sessions and orientation for new Trustees.
  15. Performs other duties as required or assigned.
Minimum Qualifications:
  • Master's degree in a business discipline with a minimum of 10 years of supervisory management experience in health care required. 
  • Compliance Officer, Certified Public Accountant (CPA), or legal background desired.
  • Prior audit and compliance experience working at an Academic Medical Center and/or complex/matrix healthcare provider system is required.
  • Demonstrated experience in planning and performing effective analysis and appraisals of complex organizations, functions and systems. 
  • Certified in Healthcare Compliance (CHC) and strong working knowledge of billing and coding preferred.

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