Assistant Compliance and Privacy Manager - JD

Atlantic Health System; Morristown (NJ); On-site; USD 85,000 - 115,000; Full time

Job summary

Atlantic Health System in Morristown, NJ seeks an Assistant Compliance and Privacy Manager to support the corporate compliance program and privacy initiatives. The role will help implement policies, conduct investigations, and enhance risk management across multiple areas including HIPAA, information governance, and regulatory requirements.

The incumbent will coordinate internal audits, deliver training, and collaborate with legal, IT security, and operations to reduce risk and ensure adherence

Responsibilities

• Support the Director of Corporate Compliance and the Senior Compliance and Privacy Manager to implement policies and procedures, train staff, and conduct investigations.
• Conduct compliance program effectiveness reviews based on the seven elements of an effective program per HHS guidance, DOJ, CMS, and related standards.
• Maintain a system of reporting and ensure the integrity of all compliance investigations.
• Direct and coordinate internal audits and monitor HIPAA/Patient Privacy compliance.
• Review the organization’s compliance posture to promote conformity to laws, policies, patient privacy, and IT security.
• Follow up on reported incidents of non-compliance; coordinate investigations and prepare reports.
• Assess policy compliance and assist in updating or developing new policies.
• Evaluate potential billing, Stark, anti-kickback, or patient privacy risks and implement mitigations.
• Manage and investigate compliance questions and incidents with management, legal, and HR as needed.
• Develop analytics for monitoring, auditing, case management, and federal reporting; prepare organizational communications and training.

Job description

The Assistant Compliance and Privacy Manager, who will report to the Senior Compliance and Privacy Manager (or his/her designee), shall be charged with assisting in the oversight, in pertinent part, the following compliance risk areas: (i) general compliance and compliance program effectiveness; (ii) fraud, waste and abuse and Deficit Reduction Act of 2005 workforce member and contractor compliance; (iii) patient and employee confidentiality, organizational privacy, information governance, and data risk classification; (iv) accountable care organization compliance; (v) Medicare C & D/Medicare Advantage compliance program requirements; (vi) Federal healthcare program compliance; (vii) vendor management-related compliance issues; and (viii) other assigned risk areas identified through organizational experience, risk identification activities, or regulatory mandates.

• The Manager will support the Director of Corporate Compliance and Senior Compliance and Privacy Manager (or their designees) to ensure implementation of appropriate policies and procedures, support compliance training, conduct investigations.
• Assist in the conduct of compliance program effectiveness reviews based on the seven (7) elements of an effective compliance program as set forth in: (i) relevant U.S. Department of Health and Human Services compliance program guidance; (ii) U.S. Sentencing Commission Guidelines Manual; (iii) U.S. Department of Justice, Criminal Division, compliance program guidance; (iv) CMS Conditions of Participation; (v) Medicare Shared Savings Program Accountable Care Organization Compliance guidance and regulatory requirements; and (vi) Medicare C & D/Medicare Advantage compliance program requirements.
• Maintain a system of reporting and ensure the integrity of all compliance investigations;
• In consultation with the Director of Compliance or the Senior Compliance and Privacy Manager, direct and coordinate internal audits, and monitor HIPAA/Patient Privacy compliance.
• The Assistant Manager reviews the posture of the Atlantic Health Compliance and Ethics Program with regard to its effectiveness to promote, prevent, detect, and resolve of instances of improper conduct to ensure conformity to state or federal laws, regulatory requirements, hospital policies, patient privacy, IT Security or the standards of conduct.
• Through the direction of their supervising compliance leader, the Assistant Manager will be responsible for following up on reported incidents of non-compliance, conducting and / or coordinating, internal investigations and prepare reports on the incidents and investigation findings.
• The Assistant Manager will be responsible for assessing compliance of the organization's policies and assist in updating or developing new policies.
• The Assistant Manager will assist in evaluating areas of potential billing, Stark, Anti-kickback compliance or patient privacy risk and collaborate with other managers within the organization to work with management to implement solutions to eliminate potential risks.
• Manage and investigate compliance questions, complaints, and reported incidents in collaboration with management, legal and human resources, as needed.
• Responsible for Compliance Program data analytics to develop reports for monitoring and auditing, case management and federal reporting.
• Responsible for developing organizational wide compliance communication plan, communications, and training programs.
• Assist the Director of Compliance and the Senior Compliance and Privacy Manager with the coordination of HIPAA Security compliance activities with the AH HIPAA Security Officer/Information Security Officer.
• Investigate HIPAA-related complaints and draft corresponding reports.
• Under the direction of the Director of Compliance or Senior Compliance and Privacy Manager, draft responses to HIPAA-related regulatory inquiries.
• In consultation with the Director of Compliance or Senior Compliance and Privacy Manager, review business associate agreements, data use agreements, and limited data set agreements and ensure said agreements are acceptable as to compliance form and meet standard form internal requirements.
• In consultation with the Director of Compliance or Senior Compliance and Privacy Manager, draft/review FCPA and OFAC contractual provisions.
• Conduct risk assessments and audits pertaining to assigned compliance risk areas.
• Conduct compliance and privacy training and education.
• Prepare PowerPoints and present educational or compliance-related topics to AH constituents.
• Under the oversight of a supervising compliance leader, draft compliance and HIPAA-related policies and procedures, as well as policies and procedures related to other assigned risk areas.
• Assist in conflict-of-interest reviews, evaluations, and determinations.
• Assist in conflict-of-interest endorsement requests reviews.
• Review applicable regulations, relevant case law, and regulatory oversight agency guidance and enforcement decisions and make, under the supervision and guidance of the Sr. Compliance and Privacy Manager, recommendations to enhance current internal controls, as necessary.