Director, Educational Compliance

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Job Type

Full-time

Description

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…