The Compliance and Privacy Manager will execute CHRISTUS' Corporate Compliance and Privacy Work Plans at CHRISTUS Good Shepherd and CHRISTUS St. Michael Health Systems. The Manager will facilitate and monitor compliance with federal and state healthcare laws and regulations at these facilities.
Under the direction of the CHRISTUS Regional Compliance & Privacy Director executes the annual Compliance Work Plans for Good Shepherd and St. Michael's.
Manages auditing and monitoring of business units to determine compliance with applicable laws and regulations.
Work with business units to identify compliance and privacy gaps and deficiencies.
Participate in the development of appropriate workflows and corrective actions to address identified gaps and deficiencies. Develop compliance and privacy risk assessments for gaps identified and make recommendations for improvements
Work with business units to develop monitoring metrics, identify and provide input on department-level policies and procedures, as appropriate, and assist in developing/delivering specialized operational training for department Associates
Maintain current knowledge of federal and state laws applicable to healthcare providers
Serve as a resource for questions regarding application of relevant laws and regulations and the compliance and privacy program policies and procedures. Research relevant compliance and privacy regulations as needed or requested and provide written guidance to affected parties.
Develop and deliver course content for targeted training initiatives as directed by the annual work plan or as identified through operational reviews or leadership requests.
Track Compliance and Privacy training completion for your facilities
Attend regional work group meetings as directed by the CHRISTUS Health Regional Compliance & Privacy Director
Investigate suspected or reported incidents involving the use, disclosure, and storage of PHI including potential breaches, patient complaints and OCR complaints
Assist the CHRISTUS Health Regional Compliance & Privacy Director in the preparation and coordination of regulatory audits, including OIG, OCR, and accreditation agencies
Prepare submission of required reporting of compliance incidents and/or HIPAA breaches to Federal and State regulators, as appropriate
Coordinate with IT Security Officer or regional designee regarding security issues
Assist in the completion of annual Compliance and Privacy risk assessment processes
Help ensure Business Associate Agreements (BAAs) are updated
Provide appropriate compliance and privacy updates to the CHRISTUS Health Regional Compliance & Privacy Director
Initiate, facilitate, and promote activities to foster awareness of compliance and privacy within all entities
Coordinate and conduct privacy monitoring "walkthroughs" at entities
Respond to and resolve compliance or privacy related issues received via the CHRISTUS Health Integrity Line
Follow the internal process for documenting and tracking the progress of investigations and mitigation of compliance and privacy issues in the incident management system (e.g., Compliance Pro, Ethics Point, etc.)
Other projects and duties as assigned
Bachelor's Degree required; prefer in business, accounting, health care administration, legal
Knowledge of healthcare legal/regulatory compliance practices
Knowledge of HIPAA Privacy Rule, False Claims Act, Stark Law & Anti-kickback statutes
Working knowledge of hospital operation processes
Knowledge of audit and investigation techniques
Minimum of 5 years general healthcare experience with knowledge of hospital operations/compliance programs.
Prefer 4 years of experience in regulatory research and knowledge of federal and state law
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.