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