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JOB SUMMARY

The Regional Clinical Compliance Director is responsible for planning, developing, and enforcing clinical compliance programs for Baylor Scott and White Health (BSWH), which may include varied nursing compliance functions and programs including regulatory compliance and accreditation activities. Leads the development of clinical compliance programs to prevent and detect non-conformance to laws, regulations, standards, and BSWH policies and ensures the implementation of a clinical compliance program for assigned area of the organization. Develops and implements strategies, policies, procedures, and practices that establish BSWH standards for compliance. Ensures compliance to all applicable laws, regulations, and accreditation standards, such as the Joint Commission and the Centers for Medicare and Medicaid (CMS). Responds and reacts to changes and developments in laws or the regulatory environment that might affect BSWH clinical compliance and implements necessary changes. Directs and coordinates the development and delivery of education related to compliance. Investigates, audits, and resolves alleged violations or incidents of nonconformance and verifies that compliance deficiencies have been corrected. Collaborates closely with executive leadership, clinicians, medical staff, operations, legal, risk management to identify and resolve compliance issues in accordance with overall BSWH business objectives. 

A region Director translates and implements strategic plans and objectives for area of responsibility. Makes final decisions on operational matters and ensures achievement of objectives. Recommends policies and organizational changes for area. Plans and executes projects and initiatives that meet annual objectives. Plans and directs the operations of a department or area, with responsibility for staffing, processes, budgets, and costs of the unit. Leads and advises subordinate(s) to meet schedules, resolve technical problems, and monitor performance. Has a larger, more complex organization or functional area than a manager. Often has one or more managers or supervisors reporting to the role.

ESSENTIAL FUNCTIONS OF THE ROLE

1. Directs clinical compliance programs for assigned area of responsibility for BSWH.
2. Recommends and implements strategic and operational plans and priorities for clinical compliance aligned to BSWH business objectives.
3. Leads clinical compliance activities to ensure assigned hospitals and ambulatory clinics comply with all required standards and have an integrated, consistent plan for continuous compliance with CMS, Texas Administrative Code, and Joint Commission standards.
4. Maintains readiness for all random and unannounced surveys by Joint Commission, Texas Department of State Health Services (TDSHS), and other regulatory agencies.
5. Reviews and recommends changes, additions, or deletions to policies, procedures, forms, documentation tools, plans of care, and other organizational plans as appropriate.
6. Consults with hospitals, corporate departments, and system-wide councils in preparation for Joint Commission and other regulatory and accrediting agency surveys.
7. Provides education on standards and regulations to corporate departments, hospital staff, and senior leadership within the organization.
8. Designs, implements, and monitors standardized assessment tools and reporting mechanisms on compliance of policies and CMS standards.
9. Directs preparation of written responses and development of corrective action plans regarding Joint Commission and other regulatory recommendations.
10. Coordinates compliance with CMS Conditions of Participation (CoPs) and recommends necessary actions to maintain compliance.

KEY SUCCESS FACTORS

1. Bachelor's degree in nursing or related field. Master's degree preferred.
2. 3+ years of experience in clinical compliance, regulatory/legal, nursing, or related experience. 
3. Experience in a leadership role preferred.
4. In-depth knowledge of healthcare laws, regulations, standards, and guidelines.
5. Registered Nurse (RN) preferred
6. Experience collaborating across multiple departments and clinical disciplines within a large, complex healthcare organization preferred.
7. Excellent problem-solving and critical thinking skills. 
8. Excellent verbal, written, and presentation skills.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

 

About Baylor Scott & White Health

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!

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