Manager - Compliance

About the Role

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

Responsibilities

• Execute the annual Compliance Work Plans under the direction of the CHRISTUS Regional Compliance & Privacy Director.
• Manage auditing and monitoring of business units to determine compliance with applicable laws and regulations.
• Identify compliance and privacy gaps and deficiencies in collaboration with business units.
• Participate in developing workflows and corrective actions to address identified gaps and deficiencies.
• Develop compliance and privacy risk assessments and recommend improvements.
• Work with business units to develop monitoring metrics and provide input on department-level policies and procedures.
• Assist in developing and 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 the application of relevant laws, regulations, and compliance/privacy program policies.
• Research and provide written guidance on compliance and privacy regulations as needed.
• Develop and deliver course content for targeted training initiatives.
• Track Compliance and Privacy training completion for facilities.
• Attend regional work group meetings as directed.
• Investigate incidents involving PHI, including potential breaches, patient complaints, and OCR complaints.
• Assist in preparing for regulatory audits (OIG, OCR, accreditation agencies).
• Prepare and submit required reporting of compliance incidents and HIPAA breaches to regulators.
• Coordinate with IT Security Officer on security issues.
• Assist in completing annual Compliance and Privacy risk assessments.
• Ensure Business Associate Agreements (BAAs) are updated.
• Provide compliance and privacy updates to the Regional Compliance & Privacy Director.
• Promote awareness of compliance and privacy within all entities.
• Conduct privacy monitoring "walkthroughs" at entities.
• Resolve compliance or privacy issues received via the CHRISTUS Health Integrity Line.
• Document and track investigations and mitigation of compliance and privacy issues in the incident management system.
• Undertake other projects and duties as assigned.

Requirements

• Education/Skills:
  • 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, and Anti-kickback statutes.
  • Working knowledge of hospital operation processes.
  • Knowledge of audit and investigation techniques.
• Experience:
  • 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.
• Licenses, Registrations, or Certifications:
  • Registered Nurse licensure in the state of employment preferred.
  • CHC and CHPC preferred.

Schedule

8AM - 5PM, Monday-Friday

Work Type

Full Time