Job Description

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$37.19 - $56.49

Schedule:

Full Time

Shift Hours:

8 Hour employee

Department:

Office of Legal Affairs

Job Objective:

Manages, implements and administers the Eisenhower Medical Center Compliance Program by monitoring compliance and patient privacy policies, conducting compliance audits and investigations, providing employee education on compliance issues, and maintaining compliance records and documentation. In the role of Information Privacy Officer, oversees the daily operations of the Information Privacy Program including, but not limited to maintenance of policies and procedures, monitoring program compliance, investigations, tracking of incidents and breaches, reporting of cases to CDPH/OCR and insuring patient’s rights in compliance with federal and state laws. Education:
Required: Bachelor’s Degree
Licensure/Certification:
Preferred: Certification in Healthcare Compliance (CHC) and/or Certificate in Healthcare Privacy Compliance (CHPC) preferred
Experience:
Required: Five (5) years of healthcare compliance experience Reports To: Chief Compliance Officer (CCO) Supervises: N/A Ages of Patients: N/A Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to maintain confidentiality, Ability to plan, develop, and present education in front of an audience, Ability to plan, organize, and prioritize multiple tasks and work independently to meet deadlines, Ability to work effectively with individuals at all levels within the organization, High attention to detail and accuracy, Knowledge of and ability to use standard business software applications for word processing, spreadsheets, databases, presentations, and e-mails, Knowledge of federal and state healthcare compliance program requirements, Written and verbal communication skills

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
2. Creates new and innovative ways to communicate compliance policies and issues to staff across the organization.
3. Stays abreast of the latest developments, advancements, and trends in compliance by attending seminars/workshops, reading professional publications, and participating in professional organizations.
4. Maintains an awareness of current laws, statutes, and regulations that impact healthcare operations.
5. Develops content for and coordinates the compliance training program including updating the program as needed to address changes to the law, results of audits and investigations, results from previous training programs, trends in Compliance Hotline reports, and guidance from federal and state agencies.
6. Trains clinical and non-clinical staff at all levels within the organization using various methods of communication to effectively communicate key compliance topics.
Oversees support staff to ensure maintenance of compliance training records including attendance logs and copies of materials distributed at training sessions.
7. Investigates compliance and privacy related matters which includes conducting interviews with clinical and non-clinical staff to gather facts.
8. Ensures timely reporting of patient privacy breaches to meet federal and state deadlines.
Documents findings and makes recommendations for corrective action plans based on investigation findings.
9. Maintains complete records of all investigations.
10. Identifies compliance risk areas that should be addressed by the Compliance Program.
11. Assists the CCO with the development of the annual Compliance Program audit plan.
12. Implements and manages the annual Compliance Program audit plan.
13. Conducts compliance audits as outlined in the Compliance Program audit plan as well as ad hoc audits at the direction of the CCO.
14. Partners effectively with organizational leaders to monitor compliance risk areas.
15. Monitors the performance of the Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.
16. Periodically reviews policies and procedures related to the Compliance Program, including patient privacy policies, to determine if revisions are necessary.
17. Coordinates compliance policy development and/or revisions with organizational leaders, when necessary.
18. Oversees support staff responsible for maintaining the Compliance Hotline database by ensuring all reports are investigated and resolved.
19. Maintains complete, accurate, and timely closure documentation of complaints from patients and staff including reports received through the Compliance Hotline.
20. Oversees support staff responsible for maintaining compliance and privacy program logs and databases.
Assists the CCO/IPO with preparing reports to the Compliance Committee of the Board.
21. Oversees, develops and delivers initial and ongoing privacy training to the workforce.
22. Manages required breach determination and notification processes under HIPAA and CMIA breach rules and requirements.
23. Initiates, facilitates and promotes activities to foster information privacy awareness within Eisenhower Health.
24. Maintains current knowledge of applicable federal and state privacy laws.
25. Establishes and administers a process for investigating and resolving privacy complaints.
26. Collaborates with the Information Security Officer to ensure alignment between security and privacy compliance programs.
27. Performs required breach risk assessment, documentation and mitigation.
28. Conducts privacy monitoring activities in coordination with the Chief Compliance Officer.
29. On an annual basis, reviews privacy policies and recommends amendments or additions as necessary.
30. In collaboration with the Information Security Officer, monitors suspected or detected patterns of inappropriate access and/or disclosure of PHI.
31. Prepares privacy reports for the Compliance Committee of the Board of Directors
32. In consultation with the Chief Compliance Officer, responds to requests from the CDPH and USDHHS OCR.
33. Performs other duties as assigned.