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
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Legal
Industries
Hospitals and Health Care
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