JOB SUMMARY:

Is responsible for determining all functions impacted by external governing organizations and ensures compliance. Serves as Compliance Officer and Privacy Officer and manages legal risk as described.

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking 

•Identifies potential areas of compliance vulnerability

•Investigates claims of non-compliance submitted through Employee Hotline or other means

•Manages all required breach determination and notification processes under HIPAA

•Manages malpractice risk through involvement in the credentialing and privileging process

•Identifies legal high risk areas through risk assessments and other means

•Reviews subpoenas and coordinates with local law enforcement as needed

Compliance, Policy, Risk Management, and Procedure

•Develops initial and ongoing compliance training for the workforce

•Serves as Compliance Officer

•Serves as Privacy Officer

•Serves as Risk Manager

•Oversees compliance with new and existing federal, state, and local regulations (including compliance requirements for HRSA’s 330 grant, the 340B discount pharmacy program, and the FTCA)

•Drafts new policies, ensuring compliance with laws and regulations

•Reviews existing policies for regulatory and statutory compliance

•Develops and maintains the organization Compliance Plan, compliance policies and procedures, and related forms

•Develops and implements privacy and confidentiality policies and procedures and related forms

•Develops and initial and ongoing privacy training to the workforce

Checking, Examining, and Recording

•Collects, organizes, and reports on audit reports

•Audits credentialing files intermittently for compliance and in anticipation of audits

•Compiles monthly and quarterly risk management reports for committee use and board review

Planning and Organizing

•Coordinates site visits and compliance reviews by State and Federal regulators 

Communication

•Provides monthly reports to the Quality Excellence Committee

•Cooperates with regulators and entities in compliance reviews or investigations

•Collaborates with the IT Security Officer to ensure alignment between security and privacy compliance programs including policies, practices, and investigations

•Collaborates with the IT Security Officer to establish an ongoing process to track, investigate and report inappropriate access and disclosure of protected health information 

•Cooperates with the U.S. Department of Health and Human Service's Office for Civil Rights, State regulators and/or other legal entities in any privacy compliance reviews or investigations

•Works with the relevant departments in overseeing patient rights to inspect, amend, and restrict access to protected health information when appropriate

•Investigates staff and liaisons with HR pursuant to disciplinary measures

•Interfaces with all departments to coordinate and resolve compliance issues

•Consults with Finance and the insurance broker regarding wraparound coverage

•Answers legal and risk management inquiries from providers

•Responds to licensing boards, Joint Commission, or other entities conducting investigations

•Coordinates with assigned counsel in the event of any malpractice claims 

•Provides liaison to outside counsel on other legal matters that cannot be handled in house

SKILLS AND ABILITIES:

•Ability to synthesize and evaluate issues and recommend solutions as appropriate

•Ability to analyze and solve problems

•Ability to multi-task, prioritize, and work under deadlines

•Ability to work collaboratively with national, state, or local auditors

•Ability to communicate and negotiate with people at all levels

•Ability to work effectively with a variety of people in a team environment

•Ability to adapt to changes/challenges in organizational strategy, priorities, and directions, and the ability to overcome resistance to change

•Ability to communicate clearly and effectively

EDUCATION AND/OR EXPERIENCE:

•Required: BS/BA in Nursing with current RN degree or Juris Doctor and barred in Maryland

•Required: Minimum of 2 years relevant experience required; 5-7 years preferred

•Preferred: Experience with FQHCs or Look-Alikes