ABOUT SHIRLEY RYAN ABILITYLAB
Shirley Ryan AbilityLab is the global leader in physical medicine and rehabilitation for adults and children with the most severe, complex conditions. By joining our team, you will be part of our life-changing Mission and Vision. You’ll work in a truly inclusive environment where diversity and equity are championed through words and actions. You’ll contribute to an innovative culture that is second to none, one that embraces curiosity, discovery and compassion. You’ll play a role in something that’s never been done before as we integrate science and clinical care to help patients achieve better, faster outcomes — as we Advance Human Ability, together.
GENERAL SUMMARY
The Chief Integrity Officer (“CIO”) will provide leadership and strategic direction in implementing, maintaining and evolving the Shirley Ryan AbilityLab (“SRAlab”) Enterprise Risk Management (“ERM”) function, including but not limited to Integrity, Corporate Compliance, Internal Audit, Privacy and other programs. The CIO will be responsible for the day-to-day oversight, planning, designing, implementing and maintaining SRAlab-wide compliance and audit programs, policies and procedures that promote a corporate culture that fosters ethical and compliant behavior and provides the basis for ensuring adequate internal controls and compliance with all laws and regulatory requirements applicable to SRAlab. In addition, this role will continue to evolve strategically the ERM to ensure high levels of integrity, compliance and to reasonably investigate any issues which could have a material impact on the organization.
The Chief Integrity Officer will consistently be a role model for compliant behavior and demonstrate support of the SRAlab statement of Vision, Mission and Core Values by striving for excellence, contributing to the team efforts and showing respect and compassion for patients and their families, fellow employees, and all others with whom there is contact at or in the interest of the institute.
The Chief Integrity Officer will demonstrate SRAlab Core Attributes: Communication, Accountability, Flexibility/Adaptability, Judgment/Problem Solving, Customer Service and SRAlab Values (Hope, Compassion, Discovery, Collaboration, and Commitment to Excellence) while fulfilling job duties.
SRAlab is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.
Required Skills
Knowledge, Skills & Abilities Required
- Juris Doctor and/or Master’s Degree in a related field of Health Care or Corporate Integrity required.
- Certifications in Healthcare Compliance and Privacy preferred.
- At least ten years of compliance work experience in a healthcare environment, preferably a hospital or academic medical center.
- At least five years of privacy related work experience in a healthcare/provider setting.
- Ensuring a culture of integrity and transparency;
- Strong leadership skills and understanding of the importance of an effective compliance plan being inculcated throughout all levels of the organization;
- Strong critical thinking and influencing skills across all organizational levels with an unbiased approach to situations.
- Ability to manage conflict effectively while showing receptivity to the ideas and concerns of others.
- Strong research and analytical skills
- Excellent oral and written communication skills. Demonstrated positive, respectful, direct and open communications across all organizational levels.
- Ability to maintain a high degree of credibility, independence, integrity, confidentiality and trust.
- Effective time management, project management, organizational and prioritization skills.
- Ability to anticipate the needs of others and deliver with timeliness and accurately, sensing the urgency of the situation.
- Strong leadership skills.
Working Conditions
- Normal office environment with little or no exposure to dust or extreme temperature.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
SRAlab is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.
Required Experience
Principal Responsibilities
THE CHIEF INTEGRITY OFFICER SHALL:
1. Implement, manage and strategically develop, as needed, the ERM:Ensure a culture of integrity and transparency, which is embedded throughout the organization.
- Identify potential areas of integrity, compliance risk, develop and implement corrective action plans and/or policies for resolution of relevant issues, and provide guidance on how to avoid or deal with similar situations in the future.
- Supervise the review, revision and formulation of appropriate policies and procedures to meet the objective of the Corporate Integrity and ERM Program to guide employees in compliance activities.
- Develop, coordinate and oversee educational and training programs to ensure that new and current employees and applicable agents are knowledgeable of, and comply with, the ERM, and pertinent laws, rules and regulations.
- Support the Revenue Cycle function to develop new processes and efficiencies within the regulatory and legal framework.
- Monitor all functions related to research integrity and compliance, including adherence to pertinent laws, rules and regulations, and advise on research compliance matters for clinical trials management, billing, contracts, grants management and time and effort.
2. Provide effective leadership, advice, and counsel to the Board of Directors and senior management on matters related to the ERM function including corporate compliance, internal audit and ethical business practices
- Ensure open lines of communication throughout SRAlab related to ERM, corporate compliance and ethical issues, including but not limited to providing guidance to management, medical staff and all employees.
- Monitor and maintain a “hotline” or other vehicles to provide employees with open access in order to provide a confidential manner to report alleged violations of standards without fear of retribution.
- Report to, and take direction by the Corporate Compliance Committee and the Finance and Audit Committee of the Board of Directors for activities related to the ERM.
3. Implement and maintain a system of management reporting that provides timely and relevant information on all aspects of ERM, including but not limited to integrity, audit and compliance issues to management and the Board of Directors.
- Develop and maintain a reporting structure to handle employee concerns regarding known or suspected violations and ensure that all reports are appropriately investigated, including tracking and resolution of each complaint.
- Implement, maintain and measure activities related to the ERM and report data to the appropriate Committees, management, and the Board which will ensure efficient processes for documenting all compliance-related initiatives and activities.
- Establish audit controls and procedures to monitor operational effectiveness and fiscal integrity.
4. Serve as the HIPAA Privacy Officer and administer the HIPAA Privacy Office, which includes overseeing the establishment, implementation and adherence to policies on patient privacy, confidentiality and release of patient information.
- Ensure all concerns related to HIPAA concerns are investigated and handled in an appropriate manner to ensure compliance with all regulations as well as policies and procedures.
- Chair the HIPAA Committee.
- Oversee the delivery of privacy training and orientation to all employees, volunteers, medical staff, applicable business associates and others as needed.
- Provide leadership in the planning, design, and evaluation of the organization’s privacy and security policies and projects.
- Serve as a liaison to regulatory and accrediting bodies for matters relating to privacy and security, including, but not limited to, the U.S. Department of Health and Human Services Office of Civil Rights.
- Work closely with the HIPAA Security Officer and other key stakeholders to ensure that the organization’s privacy protections keep pace with technological advances.
- Ensure a process is in place for receiving, documenting, tracking, investigating, and taking action on all patients’ complaints concerning SRALab’s privacy policies and patient breaches in compliance with the HITECH Act.
5. Additional ongoing duties and responsibilities shall include:
- Lead and/or manage or support specific audits to investigate compliance with policies, procedures and legal/regulatory requirements to identify and evaluate exposures and to correct defective processes. In collaboration with the Office of General Counsel and Human Resources, provide advice and support to senior management regarding any disciplinary action that may result.
- Monitor and serve as an internal authority, in collaboration with the Office of the General Counsel, regarding the healthcare regulatory environment for emerging trends and assist stakeholders in assessing any impact SRAlab and commenting to government agencies and other applicable parties.
- Oversee the administration of the ERM function, and provide direction for the activities to mitigate, at an acceptable level, the risks that may adversely affect SRALab’s ability to achieve its internal control, financial and compliance goals.
- Manage the organizational process for and evaluation, education and reporting of conflict of interests to ensure patient care, business and research are conducted in a legal and ethical manner. Respond where necessary to external agents’ requests regarding conflict of interest matters.
- Provide regular feedback to General Counsel and other members of senior management to communicate the results of integrity or compliance gaps or concerns within the organization.
- Conduct Risk assessments and identify potential areas of integrity vulnerability and risk; develop and implement corrective action plans for resolution of problematic issues and provide guidance on how to avoid or deal with similar situations in the future.
- Develop and foster an environment where responsibility and accountability for integrity and compliance with applicable laws and policies exists throughout SRAlab. Ensures leadership understand their responsibility to operate and to develop policies, programs and activities consistent with applicable laws, and provides guidance and assistance to support managers’ effort.
- Ensure that internal audit resources are appropriate, sufficient and effectively deployed to achieve the internal audit plan approved by the Finance and Audit Committee of the Board.
- Ensure the timely completion of internal auditing engagements by outside consultants.
- Ensure that reports on internal auditing engagements are provided to the Finance and Audit Committee.
- Exercise due diligence in concert with management to prevent and detect any misconduct. Undertake all reasonable steps to respond appropriately when an issue is detected and prevent future similar issues. Ensure the enforcement of compliance program standards though appropriate mechanisms in concert with the Office of General Counsel and Human Resources.
- Review complaints, concerns, or questions relative to compliance issues and provide consultative leadership and support all SRAlab.
- Oversee the Corporate Compliance Committee.
- Interact and partner with the Office of General Counsel for assistance in interpretation of regulatory requirements and/or legal advice on issues, concerns and/or risks.
- Interact and partner with all outside consultants related to internal audits on reviewing and/or assessing potential or actual risks, conducting audits and/or other projects.
- Interact with outside counsel, in conjunction with the Office of General Counsel, and consultant to discuss and assess components of the ERM.
6. Perform all other duties that may be assigned in the best interest of SRAlab.
Reporting Relationships
- Reports directly to the Senior Vice President, Chief Administrative Officer with direct access to President and Chief Executive Officer, the Chief Financial Officer as well as the Finance and Audit Committee of the Board of Directors.