Description:

Position Summary:
The Chief Compliance Officer and Associate General Counsel provides strategic leadership of the organization's compliance program while serving as a key legal advisor on hospital operations and regulatory matters. Reporting directly to the General Counsel, with organizational accountability to the CEO and Board for Corporate Compliance, this role will be crucial in helping ensure our system's adherence to applicable healthcare laws, regulations, and accreditation standards, while offering practical, solution-focused legal counsel to system leadership and our clinical staff.

Key Responsibilities:
Compliance Oversight

Develop, implement, and maintain a comprehensive centralized compliance program aligned with organizational strategy and regulatory requirements.
Provide oversight and guidance for HIPAA Privacy, HIPAA Security, and Code of Conduct compliance activities, ensuring policies, training, and monitoring are effective and up to date.
Lead annual compliance risk assessments; identify vulnerabilities and implement corrective action plans. Monitor and coordinate compliance activities across departments; report key compliance metrics to leadership and the Board.
Oversee organizational accreditation processes (e.g. DNV or TJC); prepare for reaccreditation surveys and coordinate responses.
Promote employee awareness of ethical practices through training, orientation, and ongoing education.
Manage confidential reporting mechanisms and ensure timely, consistent investigations and resolutions.

Policy & Risk Management

Oversee policy management systems; review and approve organizational policies in collaboration with department leaders.
Ensure uniform standards for drafting, revising, and archiving policies.
Collaborate with risk management, internal audit, Human Resources, and other departments to align compliance and legal practices.
Advise on enterprise risk management initiatives and contribute to strategic planning.

Legal Counsel

Assist the General Counsel with hospital system operational matters, leaning on the following knowledge and experience:
Legal fluency with federal and state healthcare laws and regulations, including Stark Law, Anti-Kickback Statute, False Claims Act, HIPAA, and other fraud, waste, and abuse regulations
Drafting, reviewing, and negotiating contract language, including those for physician services, vendor agreements, and equipment leases
Advising on corporate governance, licensing, and employment-related compliance
Supporting strategic initiatives such as affiliations, joint ventures, and new care models
Managing relationships with outside counsel, helping direct cost-efficient legal strategy
Preparing and delivering legal training to staff on relevant regulatory matters

Qualifications:
Education & Licensure

Juris Doctor (JD) from an accredited law school; license preference for MA (will consider waiving in from other states).
Certification in Healthcare Compliance (CHC) required (or obtained within 12 months of hire).
Additional certification in Healthcare Privacy Compliance (CHPC) preferred.
An advanced degree in healthcare administration, business, or related field is desirable.

Experience:

Minimum 10 years' experience in healthcare compliance and/or legal services, including at least 5 years in an acute care hospital environment.
Demonstrated expertise in healthcare law, regulatory compliance, and risk management.
Proven experience with accreditation bodies (DNV or TJC) and policy management platforms.
Strong contract negotiation and drafting skills with practical, solution-oriented judgment.

Skills & Competencies:

Excellent analytical, written, and verbal communication skills.
Strong interpersonal and leadership abilities with a collaborative, ethical approach.
Ability to manage complex projects, investigations, and cross-functional initiatives.
High degree of integrity, discretion, and professionalism.