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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, and Procedure
• Develops initial and ongoing compliance training for the workforce
• Serves as Compliance Officer
• Serves as Privacy Officer
• 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).
• 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

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
• 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 degree required.
• Preferred: Masters in a healthcare-related field or Juris Doctor
• Required: Minimum of 2 years relevant experience required; 5-7 years preferred
• Preferred: Experience with FQHCs or Look-Alikes

Read the full job description and apply online on the recuiter's web-site

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