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UW Medicine Compliance Program, Study notes of Financial Management

The compliance program of UW Medicine, including its purpose, scope, program elements, and program structure. It also discusses the roles and responsibilities of compliance officers and the enterprise compliance reporting line. attachments such as the University of Washington HIPAA Designation and the UW Medicine Compliance Code of Conduct.

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UW MEDICINE
COMPLIANCE PROGRAM
March 11, 2021
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UW MEDICINE

COMPLIANCE PROGRAM

March 11, 2021

TABLE OF CONTENTS

 - I. INTRODUCTION - II. UW MEDICINE 
  • III. OVERVIEW - A. Purpose - B. Scope - C. Program Elements
  • IV. PROGRAM STRUCTURE - A. Compliance Oversight - 1. Executive Leadership - Compliance Leadership .................................................................................................. 2. Enterprise and UW Medicine Affiliated Covered Entity (UW Medicine ACE) - B. Compliance Committees - 1. Enterprise-Level/UW Medicine ACE Committees........................................................... - a) UW Medicine Board Compliance Committee........................................................... - b) UW Medicine Compliance Governance Group......................................................... - c) UW Medicine Compliance Oversight and Implementation Steering Committee ...... - 2. Practice Plan Compliance Committees ........................................................................... - 3. Compliance Communication Venues.............................................................................. - a) Compliance Officers Group ...................................................................................... - b) Strategic Leadership Council .................................................................................... - C. Compliance Program Management and Operations ............................................................ - D. Compliance Roles and Responsibilities................................................................................. - E. Enterprise Compliance Reporting Line ................................................................................. - F. Policies, Standards, Guidelines and Procedures - G. Code of Conduct - A. University of Washington HIPAA Designation .................................................................... V. ATTACHMENTS - B. UW Medicine/UW Medicine Compliance Governance ...................................................... - C. Chief Compliance Officer/Associate Vice President for Medical Affairs - D. UW Medicine Compliance Committees - E. Core Compliance Officer Position Descriptions .................................................................. - F. Compliance Roles and Responsibilities............................................................................... - G. UW Medicine Compliance Code of Conduct - H. UW Medicine Compliance Organizational Chart

UW Medicine shares in the ownership and governance of Children’s University Medical

Group (CUMG), a pediatric practice plan founded with Seattle Children’s (Children’s); and the

Seattle Cancer Care Alliance (SCCA), founded with Children’s and the Fred Hutchinson Cancer

Research Center (FHCRC).

UW Medicine’s mission is to improve the health of the public by advancing medical

knowledge, providing outstanding primary and specialty care to the people of the region, and

preparing tomorrow’s physicians, scientists, and other health professionals.

III. OVERVIEW

A. Purpose

The purpose of the UW Medicine Compliance Program (“Program”) is to assist UW

Medicine in achieving its financial, operational, and strategic goals while maintaining

compliance with all applicable healthcare laws and regulations. The scope, structure,

core functions and activities of the Program are updated as necessary to reflect

organizational and policy changes, programmatic refinements, and best practices for

addressing compliance risk.

B. Scope

The following content areas are within the scope of the Program:

  • Compliance operations/program integrity
  • Clinical billing and documentation (facility and professional fee billing for all

clinical services including clinical research)

  • Information security, privacy, and identity theft prevention
  • Stark law and Anti-kickback statute (AKS)
  • Conflicts of interest (COI)
  • Ethics
  • EMTALA (Emergency Medical Treatment and Labor Act)

Compliance programs for other content areas (for example, research, health and safety,

pre and post award research grants and contracts, employment), other entity partners

(for example, SCCA, FHCRC, Children’s), or UW healthcare components (for example,

Dentistry, Public Health, Nursing) are within other jurisdictions.

However, UW Medicine Compliance collaborates with its external entity partners and

other parts of the UW system for any number of reasons, including but not limited to:

  • Addressing compliance issues crossing institutional or jurisdictional lines.
  • Enforcing compliance.
  • Harmonizing policies, procedures, and guidance.
  • Engaging in mutually beneficial initiatives, process improvements and risk

assessments.

  • Sharing best practices.
  • Monitoring regulatory developments, analyzing industry trends.
  • Identifying and implementing risk mitigation strategies.

C. Program Elements

The Program is founded on both risk-based and proactive core components designed

to promote and support compliance and detect noncompliance. Activities and program

elements are documented in writing, readily available for review and regularly

reported.

Specific program elements are aligned with standards established by the federal

Department of Health and Human Services Office of Inspector General (OIG), the

Office for Civil Rights (OCR) for HIPAA Privacy and Security Rules, and the United

States Federal Sentencing Guidelines, and include:

  • Senior leadership commitment and operational, executive-level, and

advisory compliance oversight committees.

  • Designation of a chief compliance officer who:

 Reports to the chief executive officer (in addition to the clinical business and

regulatory affairs officer).

 Has responsibility for overseeing UW Medicine compliance systems and

initiatives.

 Serves as chief privacy official for the UW Medicine ACE with responsibility

for developing and implementing policies and procedures required under

HIPAA.

  • Standards, including a Code of Conduct and policies and procedures to

prevent and detect violations of law, and to protect and safeguard

protected health information (PHI).

  • Internal controls to identify and mitigate compliance risk.
  • Education and outreach activities to ensure that policies are effectively

disseminated and understood by enterprise and UW Medicine ACE

members.

  • Documented development and implementation of risk mitigation strategies and

work plans, and timely reporting to executive and board-level compliance

committees.

  • Internal monitoring and auditing.
  • Reasonable due diligence to confirm that UW Medicine does not delegate

substantial discretionary authority to individuals who the organization knows or

should know, are likely to engage in illegal conduct.

  • Maintaining lines of communication, including an anonymous reporting

mechanism for employees to report possible compliance issues without fear of

retaliation.

  • Prompt investigation of reported concerns, including noncompliance with

enterprise policies, suspected overpayments, privacy complaints and

security incidents involving PHI.

  • Effective management of noncompliance, overpayments, complaints and

incidents to meet the timelines and requirements established by regulators for

repayments, disclosure and breach notifications.

  • Appropriate corrective action to reduce the impact and minimize the risk of

similar future offenses and incidents.

a) UW Medicine Compliance Committee (UWMCC)

The UWMCC is responsible for reviewing and evaluating the Program and

preparing the Chair to advise the UW Board of Regents, the UW president

and the CEO/EVPMA/Dean regarding the implementation and effectiveness

of the Program. Section E(3)(iv) of the Board of Regents Governance

Standing Orders requires CEO of UW Medicine and the chief compliance

officer to appear before the Board of Regents to report on UW Medicine

compliance programs. An annual report includes but is not limited to, the

following topics:

  • Key compliance policies and issues
  • Status of the compliance program infrastructure and reporting

relationships

  • Scope of authority of key positions
  • Current assessment of compliance risks
  • Level of resources dedicated to the compliance programs

b) UW Medicine Compliance Governance Group (CGG)

Chaired by the CEO/EVPMA/Dean or designee, the steering committee

of this group meets regularly for the purpose of strategic planning and

problem solving, risk assessment decision-making and policy approval.

Members include UW Medicine vice presidents, the CCO/AVPMA, the

vice dean for Administration and Finance, UW Medicine strategic

business officer, clinical business and regulatory affairs officer, and issue-

specific participants as needed.

c) UW Medicine Compliance Oversight and Implementation

Steering Committee (COISC)

The COISC is chaired by the CCO/AVPMA and is primarily responsible for

overseeing implementation of compliance program activities and internal

controls throughout the organization. Members include entity executive

directors, UW School of Medicine vice deans, the chief information

officer, compliance directors and major organizational stakeholders.

2. Practice Plan Compliance Committees

The boards of UW Physicians and CUMG have established physician-led

compliance committees. The UW Physicians Compliance Committee and the

CUMG Physician Education, Billing and Compliance Committee work closely with

practice plan compliance officials in developing and implementing compliance

policies, establishing effective training strategies, and advising their respective

boards. Each committee has a formal charter and generally meets monthly. All

official committee records are maintained by compliance officials.

3. Compliance Communication Venues

The size and complexity of the UW Medicine structure and its many interfaces

call for multiple communication channels to convey compliance messages and

initiatives. The following groups provide additional venues for discussion and

raising awareness about compliance issues.

a) Compliance Officers Group (COG)

Convened by the CCO/AVPMA, this group includes UW Medicine compliance

directors, non-UW Medicine compliance officials, internal audit, risk

management and operational partners. COG shares best practices and

resources, discusses issues of mutual interest/concern, and enhances the

likelihood of cross-functional collaboration for important compliance

issues.

b) Strategic Leadership Council

Chaired by the CEO/EVPMA/Dean, this group consists of

UW Medicine senior leaders who meet at least monthly to address key

operational, finance, compliance, and strategic issues.

C. Compliance Program Management and Operations

Four department directors oversee and implement program operations for specific

content areas within UW Medicine’s defined scope and jurisdiction. Program operations

include activities designed to detect and prevent noncompliance, and to mitigate risks

associated with non-compliance. Each director has associated responsibilities for

reporting, committee management and stakeholder involvement. Directors develop

jurisdiction-specific policies and procedures as needed, maintain program records, and

participate in enterprise compliance initiatives. See Attachment E for current position

descriptions.

Several departments and entities have established compliance positions

responsible for a specific scope of program activities. Although the individuals

holding these positions have different titles, they function as compliance liaisons and

interface with UW Medicine Compliance on issues of mutual concern, are members

of COG, and participate in work groups as deemed appropriate for their scope and

specialty. Positions generally report to the department or entity head; position

descriptions are established and maintained by the individual units. These positions

include the following:

1. Laboratory Medicine Compliance Liaison;

2. Pharmacy Compliance Liaison;

3. UW Neighborhood Clinics Director of Network Operations; and

4. Airlift Northwest Compliance Liaison.

Additional compliance policies may be developed by compliance officials who have

the authorized scope and jurisdiction to address regulatory or organizational

requirements affecting a subset of the system, such as specific entities, constituents or

issues. These policies have more limited application, but still are intended to

establish a definitive leadership position on certain compliance requirements. The

baseline requirements for compliance policy development apply regardless of the

policy level.

Standards are specific mandatory controls that govern an operation, a configuration, or

a process. Standards are developed and maintained by the operational area delegated

with responsibility for establishing internal controls. For example, standards governing

information security are established by IT departments in the UW Medicine ACE

(including UW Medicine IT Services, School of Medicine IT and Valley IT). Standards

undergo a formal review and approval process, and those required by HIPAA are

reviewed and endorsed by the CCO/AVPMA.

Guidelines are frequently developed to recommend best practices that do not have the

force of policy. Guidelines are generally created by organizational leaders with

appropriate scope and jurisdiction, in collaboration with key stakeholders in operational

areas.

Procedures are step-by-step instructions that, if followed, should achieve compliance

with a given policy. Procedures are typically maintained by the operational departments

charged with specific implementation responsibilities for a given policy or set of

policies. Procedures are developed in consultation with compliance officials, with

appropriate scope and jurisdiction, but are established through separate and less

formal approval and implementation processes.

G. Code of Conduct

The UW Medicine Compliance Code of Conduct includes 7 core principles, which

require all workforce members and entities to:

1. Abide by all laws, regulations, policies, procedures and standards

2. Prevent fraud and abuse

3. Promote ethical academic, clinical, research and business conduct

4. Protect patient privacy and ensure the security of protected health information

5. Practice responsible data stewardship

6. Comply with professional and ethical standards

7. Comply with emergency medicine treatment rule

These principles are fully explained in the Compliance Code of Conduct provided in

Attachment G. It is the responsibility of every UW Medicine workforce member to be

knowledgeable about and to act in a manner consistent with these standards. Where

circumstances arise that are not covered by these standards or UW Medicine policies,

an overall philosophy of honesty and integrity applies.

  • Autism Center at Center on Human Development and Disability (CHDD)
  • Psychology Clinics in the College of Arts and Sciences
  • Rubenstein Pharmacy in the School of Pharmacy (A.K.A. Hall Health Pharmacy)
  • School of Dentistry Clinics and Faculty Practice Plan (Practice Plan also known as UW Dentists) - Harborview Medical Center and Clinics - King County Public Hospital District No. 1 d/b/a Valley Medical Center and Clinics - UW Physicians Network d/b/a UW Neighborhood Clinics - The Association of University Physicians d/b/a UW Physicians - Summit Cardiology
  • The UW Medical Center and Clinics
  • Hall Health Center
  • Airlift Northwest
  • Department of Pediatrics Molecular Development Lab

University of Washington UW Medicine – Affiliated Covered Entity Non-UW Medicine Healthcare Components (part of UW legal entity)

University of Washington

Healthcare Components

University of Washington UW Medicine Healthcare Components (part of UW legal entity)

Other Healthcare Components (non-UW legal entities)

University of Washington (UW) HIPAA Designation

A. University of Washington HIPAA Designation

C. Chief Compliance Officer/Associate Vice President for Medical Affairs

UW MEDICINE

POSITION DESCRIPTION

CHIEF COMPLIANCE OFFICER, UW MEDICINE AND ASSOCIATE VICE

PRESIDENT FOR MEDICAL AFFAIRS, UNIVERSITY OF WASHINGTON

SUMMARY POSITION DESCRIPTION

The Chief Compliance Officer, UW Medicine/Associate Vice President for Medical Affairs, University of Washington (CCO/AVPMA) reports to the CEO, UW Medicine, Executive Vice President for Medical Affairs and Dean of the School of Medicine (CEO/EVPMA/Dean) and the Clinical Business and Regulatory Affairs Officer, UW Medicine, Associate Vice President for Medical Affairs, UW and is responsible for the following:

  • Maintaining and evolving an effective compliance program covering fraud, waste and abuse prevention (e.g., clinical billing, Stark Law and Anti-Kickback Statute), Health Insurance Portability and Accountability Act (HIPAA) privacy and security, Emergency Medical Treatment and Active Labor Act (EMTALA), ethics, professionalism, conflicts of interest and identity theft prevention;
  • Assuring coordination and collaboration with affiliated organizations and other UW compliance programs (e.g., research, environmental health and safety, scientific integrity) and assurance offices (e.g., internal audit, risk management, information technology);
  • Leading UW Medicine's compliance systems and initiatives, working closely with the UW Vice Presidents for Medical Affairs (President, UWM Hospitals & Clinics UW Medicine, UW Medicine, Chief Business Officer, Chief Medical Officer, Chief Advancement Officer, and Chief Financial Officer);
  • Ensuring effective communication and collaboration between compliance program officers, entity executives and operational stakeholders;
  • Maintaining a direct relationship with the UW Medicine Compliance Committee;
  • Serving as a member of UW Medicine's senior leadership team.

The CCO/AVPMA has an important role in the development of strategies and initiatives to advance the UW Medicine mission of improving the health of the public. Important work required to advance the UW Medicine mission includes, in part, the delivery of advanced medical diagnosis and treatment services, clinical support for the education of medical students and graduate and post-graduate trainees, and maintenance of one of the largest and most advanced university-based basic and clinical research programs in the United States. In support of these activities, the CCO/AVPMA must maintain strong working relations with the US Department of Health and Human Services, US Department of Justice, Washington Department of Social & Health^ Services^ , the Medicare intermediary for Washington state, and other similar agencies. The (^) CCO/AVPMA also represents UW Medicine for compliance issues in national professional associations, including but not limited to the Association of Academic Medical Centers (AAMC) and Association of Academic Health Centers ( AAHC).

A brief summary of the significant characteristics of the distinct responsibilities and duties of this position are outlined below.

JOB CHARACTERISTICS

DIRECT MANAGEMENT RESPONSIBILITIES

  • Maintaining and evolving a comprehensive UW Medicine Compliance Program that satisfies federal and state requirements and is subjected to periodic evaluations of program effectiveness.
  • Advise the CEO/EVPMA/Dean, and the Clinical Business and Regulatory Affairs Officer, UW Medicine, Associate Vice President for Medical Affairs, and VPMAs on the status of material compliance issues at UW Medicine.
  • As the chief staff support to the UW Medicine Compliance Committee, work with the Committee chair to develop annual schedules, manage meeting agendas and establish standard formats for reports to the Committee; prepare the annual compliance report to the UW Board of Regents; report at least annually to entity-specific boards.
  • Convene the UW Medicine Compliance Operational Implementation Steering Committee, and the Compliance Officers Group; appoint chairs of working groups; ensure effective management and administrative support of official compliance committees.
  • Provide executive leadership in matters related to the staffing, strategy, philosophy and organizational structure of the UW Medicine compliance program; determine overall staffing needs in consultation with compliance directors; recruit, hire, mentor and supervise compliance directors and other direct reports.
  • Oversee the strategic planning and management of resources to support the program and establish fiscally responsible budgets.
  • Ensure development and maintenance of an effective records management program for official compliance documents, including compliance policies.
  • Serve as signatory authority for UW Medicine compliance policies as delegated by the CEO/EVPMA/Dean.
  • Serve as Chief Privacy Officer for UW Medicine.

SHARED MANAGEMENT RESPONSIBILITIES

  • Coordinate the resolution and management of shared concerns and initiatives with entity-level executives and compliance officers, including those from Children's University Medical Group, the Seattle Cancer Care Alliance and other affiliated entities.
  • Serve as chief staff support to the UW Medicine Compliance Governance Group, working closely with the chair to develop meeting agendas and execute responsibilities identified in the group charter.
  • Collaborate with the UW Privacy Official, the UW Medicine Chief Information Security Officer, and the UW Chief Information Security Officer to address privacy and information security issues.

UW MEDICINE COMPLIANCE COMMITTEES

D. UW Medicine Compliance Committees

Group/ Scope Purpose Composition

UW Medicine Compliance Committee (UWMCC) Meets quarterly; the first Monday, in the second month of each quarter (in February, May, August and November).

Scope: Enterprise and for HIPAA, the UW Medicine Affiliated Covered Entities Duties include but are not limited to advising on the following:

  • Key compliance policies
  • Compliance program infrastructure and reporting relationships
  • Scope of authority of key positions
  • Ongoing assessment of compliance risks and the effectiveness of mitigation activities
  • Level of resources dedicated to the compliance programs
  • Monitor the progress of new initiatives, process improvement projects, and programs
  • Receive reports of relevant noncompliance and misconduct
  • Provide advice on compliance activities
  • Make recommendations to improve the effectiveness of UW Medicine compliance programs
  • Annual review and evaluation of the performance of the committee - Advise the CEO, EVPMA and Dean regarding the implementation and effectiveness of UW Medicine compliance programs. - Assure that the organizations partially owned by UW Medicine or operated as part of UW Medicine have effective compliance programs. - Provide advice on the development of the annual UW Medicine compliance report to the UW Board of Regents. - Keep the CEO, EVPMA and Dean informed of its activities and findings concerning the implementation and effectiveness of UW Medicine compliance programs. - All scheduled meetings o UWMCC member designees o Appointed community members The following non-voting individuals are also invited to attend the committee meetings on a regular basis: - CEO/EVPMA/Dean - President, UW Medicine hospitals & clinics/vice president for medical affairs, University of Washington - Chief business officer, UW Medicine/vice president for medical affairs, University of Washington - Chief financial officer, UW Medicine, vice president for medical affairs, University of Washington (CFO/VPMA) - Chief advancement officer, UW Medicine/vice president for medical affairs, University of Washington - Chief medical officer, UW Medicine/vice president for medical affairs, University of Washington - Chief compliance officer/associate vice president for medical affairs - UW Medicine strategic clinical business officer/associate vice president for medical affairs, University of Washington - President, UW Physicians - Vice dean for administration and finance, School of Medicine; and - Other non-voting individuals invited by the committee chair

UW MEDICINE COMPLIANCE COMMITTEES

Group/ Scope Purpose Composition

Compliance Governance Group (CGG) Meets monthly; on the third Friday of each month with special meetings as required.

Scope: UW Medicine, and for purposes of HIPAA, the UW Medicine Affiliated Covered Entities

Deliverables:

  • Executive-level compliance program mandates and structure
  • Leadership updates to the UW Medicine Compliance Committee
  • Reports to UW Medicine Strategic Leadership Council - Strategic compliance planning and problem solving - Support enterprise compliance program (including policies, program elements, work plan, roles and responsibilities, committee structure) - Approve enforcement mandates and related messaging - Establish risk tolerance philosophy, approve mitigation plans and allocate resources

Members are appointed by the CEO, UW Medicine/executive vice president for Medical Affairs/Dean, UW School of Medicine

  • Vice Presidents: o Chief advancement officer o Chief business officer (Chair) o Chief financial officer o President, UW Medicine Hospitals & Clinics o Chief medical officer
  • Chief compliance officer/AVPMA
  • Clinical Business and Regulatory Affairs officer
  • Vice dean, Administration & Finance, School of Medicine
  • UWP Practice Plan president
  • Issue-specific advisors: o Vice deans: Academic, Rural and Regional Affairs; Graduate Medical Education; and Research and Graduate Education o Legal counsel o Content experts (chief information officer, Information Security operations officer, compliance officers/directors, Human Resources)

UW Medicine Compliance Job Description

Working Title: Director Payroll Title: Director - 1111 Salary Grade: 11 Department: UW Medicine Compliance Unit: Compliance – Facility Billing Integrity Job Classification: Professional/Exempt Reports to: Chief Compliance Officer/Associate VP for Medical Affairs

Background

UW Medicine Compliance oversees the development and coordination of compliance programs across a wide range of risk areas, including clinical documentation/coding/billing, privacy and information security, EMTALA, hospital-related research compliance (including clinical research billing), workplace ethics, industry relations, and conflicts of interest. The program covers all UW Medicine entities, including UW Medical Center Montlake and Northwest Campus’, Harborview Medical Center, UW Neighborhood Clinics, Airlift Northwest, Valley Medical Center, UW Physicians, the HIPAA Covered Entity and the UW School of Medicine. Interfaces include other university compliance offices on issues involving UW Medicine constituents and entities.

Program functions include development of policies and standards, auditing, monitoring, education/outreach, investigations, risk assessment and mitigation, regulatory monitoring and program modification, and on-going evaluation and reporting of program effectiveness.

UW Medicine Compliance operates under the strategic guidance of the Chief Compliance Officer, UW Medicine/ Associate Vice President for Medical Affairs, UW (CCO/AVPMA). Compliance Officers and Directors with specific subject matter expertise direct program activities, report directly to the CCO/AVPMA and have dotted-line relationships with entity executives.

Position Purpose

The Director, Facility Billing Integrity is a senior leadership position reporting directly to the CCO/AVPMA with responsibilities for overseeing and coordinating systems and initiatives required to establish an effective facility billing compliance program for UW Medicine.

At the direction of the CCO/AVPMA, the Director, Facility Billing Integrity develops and implements UW Medicine compliance program strategic goals, oversees applicable required elements of an effective compliance program as outlined by the Federal Sentencing Guidelines, directs resources to accomplish the goals and mission of the unit, and ensures efficient and effective team operations.

The Director, Facility Billing Integrity also works cooperatively with other UW Medicine Compliance directors, the CCO/AVPMA, UW Health Sciences risk managers, entity leaders, and the UW Medicine and UW information security officers to identify and resolve shared issues and concerns.

E. Compliance Director Position Descriptions

External Relations. Each element in the UW Medicine compliance program requires strategic, planning, and operational interfaces with other UW offices (including compliance officers and directors, risk management, UW attorney general, HR, IT, facilities, purchasing, contracting, accounting, financial management). The Director, Facility Billing Integrity serves as the Facility Billing Integrity team’s main point of contact for those interfaces.

The Director, Facility Billing Integrity provides strategic advice, recommends policy, collaborates on risk management activities, recommends and reports on compliance initiatives and program activities, coordinates resolution of issues across all four entities, and collaborates with entities related to issue management, inquires/investigations, and operational advice to help mitigate organizational risk.

The Director, Facility Billing Integrity serves as primary point of contact for all external government reviews related to Facility Billing Integrity or delegate authority as appropriate; coordinate assessments and ensure timely responses; communicate openly and promptly with payers, the OIG and other external parties as deemed appropriate and maintain good relationships with all of these parties.

Internal Operations. Internally, the Director, Facility Billing Integrity works closely with the CCO/AVPMA to develop unit-wide expectations for employees, maintain and monitor staffing levels, identify and document critical knowledge-skills and attributes for employees, and establish strategic plans for recruiting and retaining quality staff. The Director, Facility Billing Integrity ensures that the performance evaluation achieves unit goals for excellence and employee motivation.

This position requires leadership and responsibility overseeing the operational requirements of the facility billing integrity for the UW Medicine entities that bill for facility services.

The Director, Facility Billing Integrity is a full partner with the CCO/AVPMA in developing the short-term and long-range strategic goals for both unit-based and system-wide compliance operations, initiatives, and projects, and serves as project director for major initiatives.

As a confidential assistant to the CCO/AVPMA, the Director, Facility Billing Integrity uses discretion to advance issues on behalf of the CCO/AVPMA and operates independently using judgment and discretion to handle sensitive operational, implementation, and organizational concerns.

Position Complexities:

This position has substantial authority and responsibility for directing/controlling UW Medicine Compliance operations and resources of the program specifically related to Facility Billing Integrity unit of the division; and is accountable for results/resolutions. Ability to independently formulate and recommend finalized operational elements, documents substantiating the need, and outlining the requirements for, institutional practices and procedures, infrastructure, and outreach. Ability to determine compliance with internal and external regulations and policies; and act on behalf of leadership towards the operational and program goals of the unit and the compliance-related efforts throughout the health system

Position Dimensions and Impact to the University:

This position provides leadership and has responsibility overseeing the operational requirements of the UW Medicine Compliance Facility Billing Integrity program as it affects the UW Medicine entities that bill for facility services.