Manager Privacy and Compliance Education

Summary:

Under the general supervision of the Vice President Corporate Compliance and Internal Audit is directly responsible for the operations of Privacy and Education portions of the Compliance Program and collaborates to execute the Brown University Health Compliance Plan. Directs the staff executing Brown University Health*s Privacy Program who monitor employee access to protected health information maintain HIPAA Privacy log perform security breach analysis and make required reports to federal agencies. Directs staff maintaining the Compliance Program employee reporting line (Response Line). Directs and performs special investigations as requested and in compliance with Brown University Health policies and federal and state regulations. Facilitates and directs compliance and privacy training to employee and physician staff. Prepares a written summary of work often under Attorney Client Privilege where problems are found and makes recommendations to correct.

Responsibilities:

Responsible for directing and maintaining Brown University Health*s Privacy Program by ensuring that sufficient procedural guidance and training has been developed; relevant policies created employees are following these policies and receiving required training etc. Provides Privacy training as required reviews and updates Privacy Training ensures employees are completing such training etc. Performs breach analysis and federally mandated reporting.

Rounds weekly at assigned hospitals or physician groups to educate collaborate and communicate with staff regarding Brown University Health*s Compliance & Privacy program.

Investigates mitigates and educates staff regarding reported Compliance and/or Privacy compromises at assigned hospitals or physician groups.

Directs staff maintaining the Compliance Program confidential employee reporting telephone line by responding to questions regarding Compliance Policy or Regulatory interpretation or performing resulting follow-up investigations on substantive *hot line* complaints.

Collaborates with privacy team members on the enhancement of the *hot line* and subsequent reporting trending results on a monthly quarterly and annual basis.

Assists the Vice President Corporate Compliance and Internal Audit in the preparation meeting presentations and follow up actions for the Audit & Risk Committee and System Compliance Committee.

Responsible for the required annual reporting to the Office for Civil Rights (OCR) on all privacy compromises that are risk assessed to be reportable privacy breaches and associated mitigation follow up actions because of the privacy breach. This is accomplished by scheduling and facilitating quarterly reporting sessions with the Senior Compliance & Privacy Specialists.

Supervises staff and participates in the process to organize conduct privacy investigations and audits to ensure compliance with Brown University Health policies and federal and state rules. In consultation with the Vice President Corporate Compliance and Internal Audit Office of General Counsel; and often Senior Management develops investigatory work steps or audit program guidelines and objectives.

Oversees the working papers such as privacy questionnaires so that sufficient competent and evidential matter is obtained. Where applicable maintains workpapers to protect Attorney Client Privilege.

Prepares written reports with and for the Vice President Corporate Compliance of privacy investigations both internal and from regulatory agencies which include factual findings and recommendations. (Level and quality of report and recommendations would normally require minimal revision).

Cooperates with regulatory third party external auditors and consultants. Review results of test checks and other findings to identify further examination. Collaborate as needed to discuss findings of special problems.

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Acts as the Affiliate Privacy Officer for Brown University Health Corporate Services and participates in all such privacy activities including a monthly privacy log for review.

Coordinates and oversees the collection of the monthly review of the privacy logs from the Affiliate Privacy Officers at each hospital .

Responsible for scheduling and monitoring work assignments and reprioritizing as necessary to maximize productivity. Orients new staff provide ongoing review of work to ensure accuracy and consistency of methodologies and serve as a functional resource.

Responsible for facilitating Compliance Education on an annual basis and ad hoc throughout the year. This includes proactive assessment of topics and in time training as well as Annual Mandatory Compliance training.

Monitors the tracking and effectiveness of this training on a monthly and annual basis for the system and by hospital/physician group.

Collaborates with other staff to develop new modalities of training and provide compliance and privacy education to Brown University Health employees on general or specific issues when needed.

In collaboration with the Manager of Compliance & Program Effectiveness facilitates execution of the Brown University Health Compliance Plan designed to measure the risk of non-compliance demonstrate the effectiveness of the Program or enhance the level of system-wide compliance. This process includes working with respective departmental staff and stakeholders as well as the Vice President of Corporate Compliance & Internal Audit.

Responsible for routine weekly meetings with Human Resources staff to ensure timely processing of collective privacy and compliance cases.

Facilitates an annual meeting with Human Resources leadership to discuss trends and patterns of privacy compromises and Imprivata (electronic privacy monitoring) results.

Responsible for the annual review of the Notice of Privacy Practices which will include representatives from legal and registration.

Assists the Vice President Corporate Compliance and Internal Audit and Office of General Counsel by performing investigations arising from complaints received via the hot line or because of federal or state investigations.

Performs other related duties as required.

Other information:

BASIC KNOWLEDGE:

A bachelor*s degree in science or in a healthcare operations related profession is required. Master*s degree encouraged..

Certification in healthcare privacy required by Health Care Compliance Association (CHPC) is strongly preferred. Candidates willing to take this test will be considered.

Certification in healthcare compliance by the Health Care Compliance Association (CHC) is required.

General knowledge of health care operations both in a hospital and ambulatory practice environment.

General knowledge of the electronic health record sufficient to conduct privacy reviews to conduct patient privacy audits in the electronic health record.

Full knowledge of HIPAA Privacy Act HIPAA Security Act Office for Civil Rights guidance*s and communications and HHS Office of Inspector General Compliance Guidance.

Knowledge of personal computer software applications that interface with various billing and training databases.

Knowledge of spreadsheet and word processing applications.

EXPERIENCE:

Minimum of two years of Corporate Compliance/Privacy/Health Information Services/Health Care Operations experience to demonstrate broad-based knowledge of health care operations and federal and state laws.

Demonstrated strong written and oral communication skills education/training experience supervisory and problem-solving skills and project management skills and personal computer application skills.

INDEPENDENT ACTION:

Perform independently within Brown University Health*s administrative policies and procedures referring unusual problems to the Vice President Corporate Compliance and Internal Audit

SUPERVISORY RESPONSIBILITY:

Functional supervision for four full-time employees. Supervision consists of assigning work scheduling providing guidance and counsel and completing and rendering performance evaluations.

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown University Health Corporate Services USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union

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