General Counsel and Chief Compliance Officer

Position Title: General Counsel and Chief Compliance Officer (GC/CCO)

Location: Dallas, TX (North) or Austin, TX (South)

Reports To: General Counsel reports to President & CEO; Chief Compliance Officer reports to the CEO with a dotted line report to the Board of Directors and a direct reporting relationship to the Governance Committee of the Board

Supervises: Vice President of Quality and Risk Management

Summary

• The General Counsel is an attorney with experience advising healthcare organizations on issues such as governance, compliance, corporate and real estate transactions, labor and employment, and litigation. The General Counsel will develop and maintain the legal capacities of PPGT and its affiliated entities (the “Affiliate”). The General Counsel reports directly to the President and CEO and works closely with the Board of Directors. They are also an integral part of the Executive Leadership team. The General Counsel is responsible for personally managing the legal and regulatory issues associated with daily tactical decisions, as well as long-term strategic initiatives. This involves obtaining and overseeing the judicious and cost-effective use of outside counsel, particularly on a pro bono basis.
• The Chief Compliance Officer works to ensure that the Affiliate conducts its business in accordance with the highest standards of ethical business practices and in compliance with all state and federal laws and regulations. The Chief Compliance Officer will serve as a role model for high ethical standards and will work to create a culture of corporate integrity. Ensures productivity expectations, customer service and compliance standards are maintained. Abides by the organization’s mission in performing job duties. Demonstrates an understanding of and commitment to quality healthcare and excellent customer service

Essential Job Functions and Expectations

• General Counsel Essential Functions:
• Assists in the planning and strategic development process by providing legal and business advice relating to the operation of the Affiliate.
• Participates in the definition and development of corporate policies, procedures, and programs and provide continuing counsel and guidance on legal matters and on the legal implications of all matters.
• Ensures compliance with general health care law, health insurance law, regulatory and compliance statutes (HIPAA, Stark, Anti-Kickback, etc.), as well as corporate and tax law requirements.
• Drafts and revises Affiliate policies, regulations, communications, bylaws, briefs, and legal responses as needed.
• Evaluates the merit of all litigation filed against or on behalf of the Affiliate, and work with the Executive Leadership team, PPFA Litigation and Law, and/or outside counsel to define a strategic defense and approve settlements of disputes where warranted.
• Manages all litigation filed against or on behalf of the Affiliate, and work with PPFA Litigation and Law and/or outside counsel to draft documents, answer discovery requests, prepare witnesses, attend depositions, conduct trial, etc.
• Drafts, negotiates, and oversees contracts, including professional service agreements, affiliation agreements, master service agreements, business associate agreements, non-disclosure agreements, facility use agreements, and independent contractor agreements for all areas of the Affiliate, including the education of staff regarding contractual requirements.
• Ensures legal awareness training and legal subject-specific training for all staff. Effectively communicates the importance of legal documents such as preservation notices, contracts, subpoenas, affidavits, etc.
• Orients new staff, Board members, and volunteers to the legal issues faced by the Affiliate.
• Provides consultation and guidance to Health Services leadership and staff regarding corporate bylaws, the Affiliate’s Medical Standards and Guidelines, operating rules and procedures, health services staff and legal issues, credentialing, peer review, and policies and procedures.
• Directs activities of staff in the investigation and management of potential risks and subject insurance claims.
• Attends meetings of the various Boards of Directors, committees, and other Board functions in order to provide reports pertaining to legal activities and consultation relating to Board procedures, bylaws, governance and other legal matters.
• Oversees the selection, retention, management, and evaluation of, and budget for, all outside counsel. Seek out and retain pro bono counsel where needed and/or available.
• Engenders trust among staff and patients, providing timely advice and counsel that non-lawyers will both understand and heed.
• Acts as corporate representative for licenses and license applications where needed (e.g., pharmacy, facility).
• Effectively represents the Affiliate to inside and outside constituents and stakeholders through community service, formal presentations, and marketing and legislative efforts.
• Assists the Affiliate as needed with PPFA Accreditation process, as well as during any regulatory audit or investigation.
• Be on-call as necessary to address staff questions and meet the needs of a dynamic healthcare organization.
• Chief Compliance Officer Essential Functions:
• Formulates, implements, and assesses the Affiliate-wide compliance program, including oversight of quality assurance functions.
• Ensures compliance awareness training and compliance subject-specific training for all staff. Effectively communicates the importance of compliance with state and federal laws and regulations, funder requirements, and accreditation standards across all levels of the Affiliate.
• Supervises the Vice President of Quality and Risk Management in facilitating the compliance committee meetings as needed.
• Ensures all compliance related reports and matters, including those that are reported via the Helpline, suggestion boxes, or via any other reporting function, are investigated and resolved as appropriate.
• Formulates and monitors the Affiliate’s compliance activities regularly and oversee internal and external reviews.
• Proactively identifies and resolves potential issues of non-compliance; coordinate with the Chief Operating Officer to ensure operating procedures are tailored to mitigate potential compliance risks.
• Works with the Chief Human Resources Officer on the implementation of appropriate retraining and/or disciplinary protocols for employees, volunteers, or independent contractors who do not meet or follow compliance requirements, Affiliate policy and/or the Code of Business Conduct.
• Works with the Chief Human Resources Officer to provide legal advice relating to the investigation of employee complaints.
• Liaison to outside counsel to oversee and administer the process of self-reporting to government agencies when appropriate and necessary.
• Works with all levels of management to integrate elements of the compliance program into all aspects of the organization’s operations.
• Provides compliance updates as required to the Executive Leadership Team, and the Board of Directors, including the Governance Committee.
• Manages efforts to prevent, detect and correct occurrences of healthcare fraud and abuse.
• Manages fraud risk awareness by ensuring compliance with fraud risk assessments and audits and providing fraud risk training where appropriate.
• Maintains discrete and clear written records and files of all Compliance Program activities, including all steps and determinations made as a result of investigations.
• Formulates and directs internal audit and monitoring activities, ensuring they are timely performed, that recommended actions are taken, and that assessments are performed to gauge the efficacy of compliance efforts.
• Orients new staff, Board members, and volunteers to the compliance issues faced by the Affiliate and how to identify and report such issues.
• Trains staff on how to identify, create, and conduct audits and monitoring activities for risk and compliance projects as needed.
• Oversees the Affiliate’s annual risk assessment process including ensuring written protocols of the process.
• Coordinates with the Affiliate’s HIPAA Privacy Officer and HIPAA Security Officer where needed to ensure full compliance with state and federal HIPAA regulations.
• Supervises/assists VP of Quality & Risk Management with maintenance and follow-up on the compliance-related activities report.
• Affiliate wide Expectations:
• Demonstrates and maintains a high degree of professionalism in the community.
• Adheres to the Affiliate code of conduct and all policies, procedures and protocols.
• Ability to obtain and maintain the necessary certifications in accordance with compliance requirements.
• Ability to adapt to diverse operation hours, needs and clientele of affiliate health centers.
• Must be able to travel as needed.
• Ability to think strategically and achieve organization’s goals relating to position.
• Ability to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural beliefs and practices, preferred language, and other communication needs.
• Exemplify the organization’s values: We Tend to the Team; We Respect and Honor All People; We Jump In; We Try and We Learn; We Care for our Business; and We Return to our Mission.
• General Expectations:
• Other related duties as assigned.
• Duties and responsibilities may be added, deleted or changed at any time at the discretion of management, formally or informally, either verbally or in writing.

Required Education, Licenses, Certifications & Experience

• The General Counsel and Chief Compliance Officer must (i) possess a valid and unrestricted license to practice law in the State of Texas issued by the State Bar of Texas; and (ii) obtain and maintain the necessary additional certifications in accordance with applicable law and with PPFA requirements. Must have at least 7 years of experience as an attorney advising health care organizations, preferably with some experience as an in-house attorney for a health care organization.

Other

• PPGT is an equal opportunity employer which makes reasonable accommodations to those disabled under the Americans with Disabilities act and who are willing and able to perform the essential duties of the position, with or without an accommodation.We maintain a drug-free workplace.

Essential Physical Requirements/Working Conditions

• The essential functions of the job require GC/CCO to work 40+ hours per week in the Affiliate offices and/or health centers, including nights and weekends. Must be able to work flexible hours including evenings and weekends. Must be able to bend, squat, stand, and lift up to 40 pounds. Must be able to type, operate standard office equipment, and communicate (written and oral) in a clear and professional manner. Must be able to perform assigned duties with efficiency and accuracy and maintain confidentiality.Must be able to travel as needed for affiliate business.

Applicants have rights under the Federal Employment Laws. To view these notices, please click on the following links: Family and Medical Leave Act (FMLA) poster; Equal Employment Opportunity (EEO) poster; and Employee Polygraph Protection Act (EPPA) poster.