Compliance Officer

Compliance Officer

StoneGate Senior Living

Lewisville, TX

StoneGate Senior Living, a premier provider of support services to senior care facilities, is seeking an experienced Compliance Officer to lead the organization’s compliance and ethics function and serve as its HIPAA Privacy Officer. StoneGate Senior Living provides management services to more than 30 healthcare facilities and over 3,000 employees across Texas and Oklahoma. Our managed communities provide skilled nursing, assisted living, rehabilitation, and other senior care services.

As the Compliance Officer at StoneGate Senior Living in Lewisville, TX, you will report directly to the Chief Executive Officer and provide organization-wide oversight of the company’s compliance and ethics program. This includes reviewing, developing, planning, and implementing compliance initiatives, as well as auditing, monitoring, and evaluating regulatory compliance across the organization.

Job Purpose

The Compliance Officer (CO) leads the compliance and ethics function of StoneGate Senior Living. The CO is responsible for the global oversight of the end-to-end compliance and ethics process. Oversight may involve reviewing, developing, planning, and implementing initiatives related to compliance and ethics, as well as auditing, monitoring and evaluating the effectiveness of regulatory compliance with all laws, rules, and regulations promulgated by governing bodies and third-party agencies. This includes state agencies such as the Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Inspector General (OIG), Department of Justice, and Drug Enforcement Administration. Other agencies not specific to the healthcare industry include the federal and state Department of Labor, Environmental Protection Agency, Internal Revenue Service and Occupation Safety and Health Administration.

The CO also serves as the organization’s HIPAA Privacy Officer and, in that capacity, works closely with the HIPAA Security Officer in the Information Technology (IT) Department to ensure coordinated oversight of the privacy and security of protected health information (PHI).

Essential Functions:

• Reviews and updates the Compliance and Ethics Program as required and develops an annual Compliance and Ethics Program.  Works with departmental management and subject matter experts to develop the program.

• Completes a risk assessment integrated with internal audits, which identifies high-risk areas as well as processes/functions with compliance gaps.

• Develops, on an annual basis, a compliance audit/review schedule delineating the areas identified for audit/review based on high-risk/high-priority compliance items identified in the integrated audit and compliance risk assessment and the OIG Nursing Facility Industry Segment-Specific Compliance Program Guidance published November 2024.

• Assists in development of compliance and departmental policies and procedures, as deemed necessary.

• Develops the agenda for the Compliance and Ethics Committee (CEC) in conjunction with members of the committee to include summary of audits, investigations, hotline calls, and risk areas identified.

• Annually reviews the OIG Work Plan and assigns departmental responsibility for evaluating and reporting compliance risks associated with the plan. Independently evaluates compliance risks associated with the plan.

• Prepares training materials and works with department management to deliver effective and timely compliance training to affected management and employees. Delivers training to selected audiences.

• Examines the effectiveness of established policies, standards, and procedures in assisting all levels of management in their obligation to comply with all applicable regulatory standards.

• Maintains a current understanding of regulatory trends and changes in law and advises appropriate management staff of trends affecting their activity.

• Performs compliance interviews and investigates reports of alleged non-compliance to determine the validity, nature and scope of the reports in conjunction with the designated team members.

HIPAA Privacy Officer – Areas of Responsibility:

• Serves as the organization’s HIPAA Privacy Officer, providing enterprise-wide oversight of compliance with the HIPAA Privacy Rule and applicable state privacy laws.

• Develops, reviews, and updates HIPAA privacy policies and procedures, including the Notice of Privacy Practices, and ensures consistent implementation across all facilities.

• Works closely with the HIPAA Security Officer in the Information Technology (IT) Department to coordinate administrative, physical, and technical safeguards for protected health information (PHI).

• Oversees intake, investigation, and resolution of HIPAA privacy complaints, incidents, and potential breaches, including required risk assessments and notifications to residents, HHS, and other agencies as applicable.

• Reviews and monitors business associate compliance with HIPAA requirements.

• Develops and delivers HIPAA privacy training for workforce members, management, and business associates.

• Serves as the primary point of contact for HIPAA privacy inquiries from residents, family members, staff, and regulatory agencies.

• Monitors changes in federal and state privacy laws and regulations and updates policies, training, and practices accordingly.

• Maintains documentation of HIPAA privacy compliance activities, including breach risk assessments, complaint logs, and training records, in support of audit readiness.

Secondary Duties:

• Performs management office and facility-level interviews with all key personnel involved with the process or function to verify compliance with established policies and procedures and applicable regulations. In conjunction with the departmental subject matter experts, internal audit staff and other personnel, performs other testing, as deemed necessary.

• Prepares and analyzes a narrative description of the process or function under audit/review in order to evaluate potential strengths and weaknesses and to determine the adequacy of the overall organization to ensure compliance, as deemed necessary.

• Develops audit/review programs as delineated in the compliance audit/review schedule and performs prospective audits/reviews in conjunction with the internal audit staff and other personnel as deemed necessary, except where specific professional licensing is necessary.

• Develops reports, upon completion of each compliance audit/review that detail recommendations designed to correct any potential weaknesses or areas of noncompliance discovered during the audit/review.

• Assists management of audit/review facilities/departments in developing action plans to correct potential weaknesses and ensure ongoing compliance.

• Performs follow-up of audits/reviews for reports generated by the compliance committees, external auditors, agencies, etc., to ensure action plans have been appropriately implemented.

Qualifications:

• Bachelors’ degree in related field preferably healthcare administration, accounting/finance, or nursing.

• Minimum of five (5) years of progressive healthcare compliance, regulatory, auditing, investigations, or related experience.

• Experience in skilled nursing, long-term care, and assisted living preferred.

• Strong interpersonal skills.

• Familiarity with regulatory compliance reference and Internet tools.

• Proficiency in Microsoft desktop applications including Excel, Word, PowerPoint, and Teams.

• Professional work experience with/for federal and state agencies, preferably healthcare related.

• Direct experience with departments and infrastructure.

• Flexible, self-motivated, independent.

• Prefer professional membership certification such as Health Care Compliance Association and other professional organizations promoting healthcare compliance.

• Regular, predictable and dependable attendance.

Direct Reports

• Director of Clinical IT

• Credentialing Coordinator

StoneGate Senior Living is an equal opportunity employer.