Director of Privacy & Compliance Program

Erlanger Health System•Chattanooga, TN

About The Position

Under the direction of the Chief Compliance Officer, the Director Privacy and Compliance Program has proactive operational responsibility of the EHS Privacy and Compliance Program. The incumbent develops privacy and compliance guidelines, best-practice procedures, and supporting documentation to ensure the protection, privacy and confidentiality of all protected patient and employee information and help ensure adherence to other applicable compliance laws and regulations.

Requirements

Bachelor's Degree in related field.
10 plus years' experience in health care compliance environment
Certified in Healthcare Compliance (CHC) or similar certification.

Nice To Haves

Master's Degree or Juris Doctorate
Strong investigation skills
Knowledge of Federal and State compliance laws and regulations including but not limited to fraud, waste, and abuse laws, conflicts of interest, False Claims Act, Anti-Kickback and Stark statutes and regulations, and clinical research related laws and regulations.
Prior experience working in a healthcare compliance environment including physician services, hospital services, ambulatory surgery centers, and clinical research.
Prior experience with Clinical Research compliance standards and programs including the Common Rule, FDA regulations, Medicare National Coverage Determination related to clinical research.
Knowledge of the Healthcare Insurance Portability and Accountability Act and its Privacy, Security and Breach Notification Regulations.
Excellent written and verbal communication skills
Strong presentation skills
Demonstrable working knowledge of office applications (Word, Excel, email, etc.)
Certification related to Clinical Research Compliance (CHRC or similar) and/or Certification related to Healthcare Privacy Compliance (CHPC or similar)

Responsibilities

Manage the day-to-day working of the Privacy and Compliance Programs. Monitor and validate controls to ensure that systems, documentation, and processes are compliant with internal privacy and compliance standards and privacy and compliance regulations.
Review with Chief Compliance and Privacy Officer the status of each investigation case.
Manage Incident response. Track, analyze, and draft responses to privacy and compliance complaints and inquiries.
In coordination with the Chief Compliance and Privacy Officer, review, revise, and/or draft privacy and compliance department policies to help ensure all department policy review deadlines are met and new policies are created any needed with changes to laws and regulations.
In coordination with the Chief Compliance and Privacy Officer and as requested, review operational business unit policies that have privacy or compliance implications to help ensure such policies are consistent with and in compliance with applicable laws, regulations, and EHS Code of Conduct.
Support gap analyses of existing processes to determine the privacy and compliance program needs of the organization:
Help identify and assess privacy and compliance risks.
Support the development of remediation and help ensure the implementation of corrective action plans with operational units to address the gaps identified as a result of the analyses.
Recommend and review with the Chief Compliance Privacy Officer the organization's plans, policies, procedures, and standards to meet privacy and compliance requirements.
Support the development and regular reporting on the status of the implementation of department's annual privacy and compliance workplans.
Activities, including privacy and compliance reviews, meetings with department/teams, and developing training and awareness materials.
Support the Chief Compliance and Privacy Officer in the ongoing assessment and oversight of the EH Privacy and Compliance Programs with applicable Federal and State Laws and regulations.
Oversight, participation, investigation follow-up, and team support of regular, ongoing Privacy and Compliance Program Open Case/Peer Review Meetings.
Update and manage privacy and compliance training programs for all employees, contractors, and approved system users; build a culture where privacy and compliance awareness is a priority.
Collaborate and liaise with the Chief Information Security Officer and EH Technology Management Department to ensure alignment of Corporate-wide privacy, information security, and other compliance initiatives.
Work directly with the business units and leaders to facilitate privacy and compliance risk assessment and risk management processes.
Coordinate with Information Security and other business units to support formulation, maintenance, and, as appropriate, implement the Incident Response Plan to ensure timely and appropriate resolution of the investigation of potential breaches of data.
Ensure compliance with privacy and compliance practices and consistent application of sanctions for failure to comply with relevant policies for all EHS workforce members, extended workforce, and all business associates, in cooperation with Human Resources, the Chief Information Security Officer, the Chief Compliance and Privacy Officer, senior/executive leadership and legal counsel as applicable; and
Serves as liaison for the Erlanger Western Carolina Hospital compliance committee.
Serve as liaison to the Erlanger Institute for Clinical Research
Coordinate and collaborate with the University of Tennessee College of Medicine (UTCOM) related to trainee activities including residents, medical students, and other students.
Coordinate and collaborate with the UTCOM related to research activities shared between EH and UTCOM including residents, medical students, and other students.
Service as compliance and privacy consultant to all EHS departments and affiliated entities and business associates.
Demonstrate initiative, creativity, and flexibility in problem resolution,
Exercise good judgment.
Effectively manage work time while handling more than one assignment at time.
Prioritize work assignments to ensure the appropriate work is being completed.
Demonstrate integrity, credibility and personal accountability.
Set High work standards.
Shares technical and other specialized knowledge with peers.
Demonstrate excellent oral and written communication skills; and demonstrate commitment to customer service.
The Director of Privacy and Compliance work independently with the Chief Compliance and Privacy Officer and relies on experience and judgment to plan and accomplish tasks.
Days and hours work may be variable and may include after hours on-call support; and
Other duties as assigned by the Chief Compliance and Privacy Officer.