Compliance & Privacy Officer

Cozad Community Hospital•Cozad, NE

2h•Onsite

About The Position

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.

Requirements

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.
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.

Nice To Haves

Project management experience preferred.
Health Care Compliance Association (HCCA) certification within the first year of employment
Basic Life Support (CPR)
Valid Driver’s License

Responsibilities

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.