Director, Chief Compliance & Privacy Officer - San Ysidro / Corporate

Chief Compliance Officer

The Chief Compliance Officer is responsible for establishing San Ysidro Health Center's Corporate Compliance Program. The Chief Compliance Officer will oversee all activities related to the development, implementation and maintenance of the program. The Chief Compliance Officer will ensure that the program achieves high standards through documented processes and procedures intended to ensure that the organization obtains and remains in compliance with all regulatory entities and requirements. The Chief Compliance Officer will be effective and efficient in identifying, preventing, detecting and correcting noncompliance issues within the organization. This position will report to the Executive Vice President of Operations.

Essential Functions of the Job :

• Ensures all employees are in compliance with the rules and regulations of regulatory agencies, organizational policies and procedures and that behavior in the organization meets San Ysidro Health Center's ethical standards
• Develops, initiates, maintains and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct
• Acts as the principal point of contact when responding to government investigations and queries in regard to compliance activities. Inform the CEO, Executive VP of Operations and the Board Compliance Committee of any important issues.
• Oversees the implementation and maintenance of the organization's HIPAA compliance program in accordance with the Health Insurance Portability and Accountability Act of 1996.
• Oversees compliance adherence for a variety of organizational programs, including PACE, HRSA, 340B Pharmacy, and others.
• Works with the appropriate departments and programs to ensure licensing and certification requirements are kept up to date.
• Performs ongoing compliance monitoring activities, including periodical reviews of departments.
• Conducts annual risk assessments to measure potential vulnerability and risk for all areas of the organization. Develops / implements corrective action plans for resolution of problematic issues resulting from the risk assessment and provides general guidance on how to avoid or resolve similar situations in the future.
• Develop a remediation plan to address any non-compliance areas and works with the appropriate departments to remediate issues.
• Ensures that the organization has and maintains appropriate privacy and confidentiality consent and authorization forms, information notices and materials reflecting current organization and legal practices and requirements.
• Oversee, direct, deliver, and / or ensure delivery of compliance training and orientation to all employees, volunteers, medical and professional staff and applicable business associates.
• Participates in the development, implementation, and ongoing compliance monitoring of all business associate agreements to ensure that all privacy concerns, requirements and responsibilities are addressed.
• Establishes and maintains a mechanism to track access to protected health information, within the purview of the organization and as required by law to allow qualified individuals to review or receive a report on such activity.
• Oversee and ensure the rights of the organization's patients to inspect, amend and restrict access to protected health information, when appropriate.
• Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the practice / organizations compliance policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel.
• Ensures compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the practice / organizations workforce, extended workforce, and for all business associates, in cooperation with his / her immediate supervisor, Human Resources, and legal counsel, as applicable.
• Initiates, facilitates and promotes activities to foster compliance program(s) awareness within the organization and related entities.
• Serves as a member of, or liaison to, the organizations Policy Committee. Also serves as the information privacy liaison for users of clinical and administrative systems.
• Reviews all system-related information security plans throughout the organizations network to ensure alignment between security and privacy practices as required by Federal, State and County regulations. Acts as a liaison to the IT department, as necessary.
• Works with all organization personnel involved with any aspect of release of protected health information, to ensure full coordination and cooperation under the organizations policies and procedures and legal requirements.
• Maintains current knowledge of applicable federal, state and county compliance laws and accreditation standards, and monitors advancements in information privacy technologies to ensure organizational adaptation and compliance.
• Cooperates with the U.S. Department of Health and Human Services Office of Civil Rights, other legal entities, and organizations or officers in any compliance reviews or investigations.
• Establishes an internal audit program, working with the appropriate departments to perform coding, credentialing and billing audits.
• Coordinates external audit processes of business partners and drives specific audit preparation activities for HRSA audit and other audits as assigned.
• Periodically revises the compliance program and related documentation in light of changes in law, regulatory or company policy, and the ongoing quality improvements of the program.
• Maintains a clean, safe, and organized work area at all times
• Adheres to and promotes all applicable SYH policies, protocols, procedures, and processes

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