Manager Compliance - Compliance

CHRISTUS Health•Irving, TX

17h

About The Position

The Compliance and Privacy Manager executes CHRISTUS’ Corporate Compliance and Privacy Work Plans and facilitates and monitors compliance with federal and state healthcare laws and regulations at CHRISTUS facilities. Under the direction of the CHRISTUS Regional Compliance & Privacy Director, the Manager carries out annual work plans, assesses compliance and privacy risks, supports corrective actions, and promotes awareness of compliance and privacy across organizational entities. The role includes auditing and monitoring business units, researching and interpreting relevant regulations, advising affected parties, developing and delivering targeted training, tracking training completion, investigating suspected or reported privacy incidents, and coordinating regulatory audit preparation and required reporting. The Manager also supports privacy monitoring walkthroughs, Business Associate Agreement updates, incident documentation and resolution, and coordination with IT security personnel. Other projects and duties may be assigned.

Requirements

Minimum of 5 years of general healthcare experience with knowledge of hospital operations or compliance programs.
Knowledge of healthcare legal and regulatory compliance practices.
Knowledge of the HIPAA Privacy Rule, False Claims Act, Stark Law, and Anti-kickback statutes.
Working knowledge of hospital operational processes.

Nice To Haves

Bachelor’s degree, preferably in business, accounting, healthcare administration, or legal studies.
4 years of experience in regulatory research and knowledge of federal and state law preferred.
Registered Nurse licensure in the state of employment preferred.
CHC and CHPC certifications preferred.

Responsibilities

Execute annual Compliance Work Plans under the direction of the CHRISTUS Regional Compliance & Privacy Director.
Manage audits and monitoring of business units to assess compliance with applicable laws and regulations.
Work with business units to identify compliance and privacy gaps and deficiencies, develop risk assessments, and recommend improvements.
Participate in developing workflows and corrective actions to address identified gaps and deficiencies.
Work with business units to develop monitoring metrics, provide input on department-level policies and procedures, and assist with specialized operational training.
Maintain current knowledge of federal and state laws applicable to healthcare providers and serve as a resource on relevant laws, regulations, and program policies and procedures.
Research compliance and privacy regulations and provide written guidance to affected parties.
Develop and deliver targeted training content and track Compliance and Privacy training completion for assigned facilities.
Attend regional work group meetings as directed by the CHRISTUS Health Regional Compliance & Privacy Director.
Investigate suspected or reported incidents involving use, disclosure, or storage of PHI, including potential breaches, patient complaints, and OCR complaints.
Assist the CHRISTUS Health Regional Compliance & Privacy Director with preparation and coordination of regulatory audits, including OIG, OCR, and accreditation agency audits.
Prepare required reports of compliance incidents and HIPAA breaches for Federal and State regulators, as appropriate.
Coordinate with the IT Security Officer or regional designee regarding security issues.
Assist with annual Compliance and Privacy risk assessment processes and help ensure Business Associate Agreements are updated.
Provide compliance and privacy updates to the CHRISTUS Health Regional Compliance & Privacy Director.
Initiate, facilitate, and promote activities to foster compliance and privacy awareness across entities.
Coordinate and conduct privacy monitoring walkthroughs at entities.
Respond to and resolve compliance or privacy issues received through the CHRISTUS Health Integrity Line.
Document and track investigations and mitigation of compliance and privacy issues in the incident management system.
Perform other projects and duties as assigned.