Compliance amp Privacy Officer

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Compliance & Privacy Officer

Duties: Reporting to both the CEO of the Medical Center and the AVP for Compliance for the University, will direct the planning, execution, monitoring and evaluation of an effective compliance program for the Medical Center and the Transitional Care Hospital (TCH) and coordinate those compliance requirements that relate to the clinical enterprise with the School of Medicine and the University Physicians Group (UPG) (the Compliance Program). Will work with Medical Center and TCH finance and operations departments to help implement necessary standards and safeguards for compliant operations. Responsible for compliance with federal and state laws relating to the privacy and access of patient health information for the Medical Center and the TCH (the Privacy Program). Will work with information technology and other operational departments to help implement standards and safeguards for the privacy and security of patient information. Will collaborate with various individuals and offices within the Health System and the Academic Division for both the Compliance Program and the Privacy Program, including but not limited to, the Chief Financial Officer for the Medical Center and the TCH, the University Counsel’s Office, the Chief Audit Executive, the Compliance Officer for UPG, the Chief Information Officer for the Medical Center, the Chief IT Security Officer for the Medical Center, the Special Advisor to the EVP for Health Affairs, as well as others within the Health System and the University as needed to achieve program objectives. Develop and maintain a Compliance Program that conforms to applicable federal and state laws as well as to Medical Center, TCH and other Health System policies and standards. Conduct risk assessments as necessary to identify Compliance Program requirements. Direct activities or compliance audits established to monitor or investigate compliance with standards and procedures implemented by the Compliance Program collaborating with the University Counsel’s Office in light of legal duties imposed by government agencies and others. Arrange for investigations and required reporting of perceived non-compliance for Compliance and Privacy Program matters, including responsibility for monitoring the Compliance and Privacy Reporting Systems, and provide recommendations regarding necessary controls to prevent further non-compliance or breaches. Demonstrates ability to analyze problems and issues from a variety of perspectives and to understand legal, privacy, risk, and operational impact of decisions. Interprets significance of findings, resolves issues, make recommendations and offers solutions for decisions. Integrate the Compliance and Privacy Programs into the operations of the Medical Center and the TCH so they are not duplicative of other efforts, are values based, and are adaptive to change. Work with appropriate areas within the Health System to develop written policies, procedures, and programs that promote the Medical Center and TCH commitment to compliance in all areas identified as risk areas within the Compliance Program. Oversee activities related to adherence to these policies and procedures. Promote a culture within the Medical Center that focuses on prevention, detection, and resolution of inappropriate conduct as defined in the Compliance Program. Direct efforts to communicate Compliance and Privacy Programs. This includes written materials, education and training programs that are designed specifically to promote understanding of compliance issues, laws, regulations and privacy as well as consequences of non-compliance for all employees and medical staff of the Health System. Maintain a communication process such as a confidential “Compliance Help Line” as well as Compliance and Privacy Office contacts to respond to compliance or privacy-related questions, inquiries, or complaints. Develop monitoring tools and regular written compliance and privacy reports in order to communicate activities as required by or needed for the CEO, the AVP for Compliance, or the Board of Visitors. Oversee Medical Center responses to external regulatory agencies such as the Centers for Medicare and Medicaid Services and the Federal Office for Civil Rights relating to Compliance and Privacy matters. Ensure periodic assessment and ongoing monitoring of key elements of the Compliance and Privacy programs are conducted. Coordinate activities, policies, audits, and investigations with other compliance officials and internal auditors of the University and the Health System in order to assure that all programs are complementary. Manage the day-to-day operations of the Compliance and Privacy office, including supervision of staff. Communicate effectively and establish cooperative relationships between entities of the University and the Health System. Serve as an example of integrity, being trusted, authentic, self-aware, and above reproach. Operate by and adhere to the Health System's core values, including ASPIRE and Be Safe, and hold others accountable for them.

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