SUMMARY:

The Compliance and Privacy Manager will execute CHRISTUS’ Corporate Compliance and Privacy Work Plans. The Manager will facilitate and monitor compliance with federal and state healthcare laws and regulations at CHRISTUS facilities.

REQUIREMENTS:

• Bachelor’s Degree preferred in business, accounting, health care administration, or 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 5 years of 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
• Registered Nurse licensure in the state of employment preferred.
• CHC and CHPC preferred

• Under the direction of the CHRISTUS Regional Compliance & Privacy Director executes the annual Compliance Work Plans.
• 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