Compliance & Privacy Officer

Job Description

Job Description

Description:

Job Title: Compliance Officer & Privacy Officer

Division: Administration

Department: Compliance

Supervisor: CEO & Hospital Board of Directors

Status: Exempt; Full-Time

Approved Date: 10/17/2024

Our Mission: To improve the health and well-being of the communities we serve demonstrating compassionate, patient-centered care.

Summary

The Compliance Officer & Privacy Officer’s primary responsibility is to provide leadership, strategic direction, and oversight of regulatory compliance for Cozad Community Health System. This position develops, assesses, and maintains systems or processes for compliance to regulatory standards required by CMS and other governing bodies. Also responsible for compliance with all aspects of Health Insurance Portability and Accountability Act of 1996 (HIPAA). Provides feedback on regulatory indicators and participates in quality assurance monitoring in accordance with the philosophy, goals, and objectives of Cozad Community Health System.

Essential Duties and Responsibilities

This description intends to describe the general nature and level of work performed by employees assigned to this job. It is not intended to include all duties, responsibilities, and qualifications. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Develops, initiates, maintains, and revise policies and procedures for the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.
• Develops and periodically reviews and updates Standards of Conduct to ensure continuing relevance in providing guidance to management and employees.
• Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Corporate attorney as needed to resolve difficult legal compliance issues.
• Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or conducting investigative procedures. Develops and oversees a system for uniform handling of such violations.
• Acts as an independent review and evaluation to ensure that compliance issues/concerns within CCHS are being appropriately evaluated, investigated, and resolved.
• Monitors, and as necessary, coordinate compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
• Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.
• Provides reports on a regular basis, and as directed or requested, to the Compliance Committee, Board, and Senior Leaders informed of the operation and progress of compliance efforts.
• Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Institutes and maintains an effective compliance communication program for CCHS, including promoting use of the Compliance Hotline, heightened awareness of Standards of Conduct, and understanding of new and existing compliance issues and related policies and procedures.
• Works with Human Resources and others as appropriate to develop an effective compliance training program, including appropriate new hire training and annual training for all employees and managers.
• Manages contracts for CCHS and makes recommendations for legal oversight as needed.
• Provides guidance and assists in the identification, implementation, and maintenance of CCHS’s HIPAA policies and procedures.
• Provides leadership in CCHS’s confidentiality and privacy activities.
• Conducts periodic walk-through assessments and ongoing compliance monitoring activities to identify potential areas of vulnerability. Develops and oversees follow-up monitoring plans.
• Performs initial and periodic information privacy risk assessments and conducts related ongoing compliance monitoring activities in coordination with CCHS’s other compliance and operational assessment functions.
• Ensures CCHS develops and maintains appropriate privacy and confidentiality consent and authorization forms, information notices, and other materials reflecting current legal practices and requirements in conjunction with CCHS’s legal counsel, senior leadership, key departments, and committees.
• Establishes a mechanism to track access to protected health information (PHI) and reports on such activity to the Compliance Committee.
• Ensures consistent application of sanctions for failure to comply with privacy policies and procedures for all employees and all business associates, in cooperation with the Director of Human Resources, Compliance Officer, administration, and legal counsel if necessary.
• Works with the HIM Leader and other department leaders in overseeing patient rights concerning their right to protected health information (PHI).
• Works with department leaders to understand and manage process improvements to ensure efficiencies and compliance.
• Follows all HIPAA guidelines and promotes and ensures patient safety.
• Fulfills mission statement by performing job duties with a high level of customer service while contributing to a positive and professional environment.
• Special projects and other duties as assigned.

Supervisory Responsibilities

• No supervisory responsibilities.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands and fingers to handle or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must regularly lift and/or move 10 pounds and must occasionally push, pull, and assist with lifting up to 300 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the hospital and clinic environment is usually moderate.

Equal Employment Opportunity

Cozad Community Health System is committed to hiring and developing the most qualified employees from the available workforce in the communities we serve.

Equal employment opportunity has been, and will continue to be, a fundamental principle at Cozad Community Health System, where employment is based upon personal capabilities and qualifications without discrimination and retaliation because of veteran status, uniformed service member status, race, color, national origin or ancestry, creed, religion, sex, sexual orientation, gender identity or expression, age, pregnancy (including childbirth, lactation, and related medical conditions), national origin or ancestry, physical or mental disability, genetic information (including characteristics and testing), or any other protected characteristic as established by applicable local, state, or federal law.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

• Bachelor’s Degree in related field, at least 2 years’ experience in compliance, or current RN licensure.
• Exceptional organization, strong analytical, and excellent communication skills required.
• Project management experience preferred.

Licensure/Certification

• Health Care Compliance Association (HCCA) certification within the first year of employment
• Basic Life Support (CPR)
• Valid Driver’s License

Language Skills

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write routine reports and correspondence.
• Ability to speak effectively with patients and employees of the organization.