#LI-AS1d

                                                                                                                                  JOB DESCRIPTION

                                                                                           Compliance and Organizational Excellence Manager

Summary/Objective:

North Shore Health is seeking an experienced, visionary compliance expert with preferred experience in Senior Living or Healthcare to support our compliance team as the Compliance and Organizational Excellence Manager. This individual will play a key role in ensuring the organization adheres to all applicable laws, regulations, and internal policies. This position also provides high-level operational support to enhance organizational efficiency and promote a culture of compliance, accountability, transparency, and continuous improvement.

Essential Functions:

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Compliance Oversight

Support day-to-day operations of the Compliance Department Support development and updating of internal policies Conduct internal audits and assist with external audits and inspections Conduct and assist with compliance-related investigations Support the development and delivery of compliance training programs Maintain documentation related to compliance activities and investigations Serve as a liaison with regulatory agencies and legal counsel as needed

Organizational Support

Coordinate cross-departmental projects and ensure timely execution Assist in drafting and maintaining standard operating procedures and policies Support leadership with data collection and reporting Facilitate internal communications and ensure alignment with organizational goals Manage confidential information with discretion and professionalism Attend and actively participate in relevant meetings, trainings, and committees as assigned Work cross functionally with Human Resources

Additional

SafetyKnow and follow North Shore Health rulesFollow North Shore Health dress and hygiene policiesDemonstrate proper use of equipmentReport equipment needs or repairsFollow North Shore Health smoking policiesUse required protective equipment (as needed during center visits)Follow infection control standards, policies and procedureResident RightsKnow Resident RightsHelp the residents/patients exercise and/or protect their rightsMaintain confidentiality of resident/patient and employee informationHIPAAFollow and adhere to North Shore Health’s policies and procedures implementing HIPAA requirements for the privacy and security of protected health informationUse and/or disclose only minimum amount of Protected Health Information necessary to complete assigned tasksReport all suspected violations of company’s HIPAA policies or procedures to North Shore Health Compliance Department

Work Environment/Physical Requirements The responsibilities of this position may involve significant travel and physical activities including standing, occasional lifting (up to 20 pounds unassisted), bending, stooping, pushing, pulling, and twisting. All employees when visiting centers may be required to provide lifting and transfer assistance to residents. Lifting and/or transferring some residents will require use of a lifting device and /or assistance from other staff.

Required Education and Experience

Bachelor’s degree in business, healthcare administration, public policy, or related field 2–4 years of experience in compliance, operations, or administrative support Strong understanding of regulatory frameworks (e.g., HIPAA, OSHA, CMS) Excellent organizational, analytical, and communication skills Proficiency in Microsoft Office Suite and document management systems

Key Competencies

Attention to detail and accuracy Integrity and ethical judgment Strong written and verbal communication Analytical thinking and problem solving Project coordination and time management Adaptability and initiative Collaboration and interpersonal effectiveness Confidentiality and professionalism

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice