General Summary

Supports and is committed to operating an effective Corporate Compliance and Privacy Program. Works under general direction to perform ongoing activities related to developing, implementing, maintaining, and adhering to policies and procedures in compliance with federal, state, and local laws and regulations.

Under general supervision, works closely with key stakeholders to implement elements of the Corporate Compliance and Privacy Program to ensure compliance with existing and new federal and state laws and regulations affecting the University of Maryland Medical System (UMMS). Responsibilities include representing assigned policy and procedure development areas, performing privacy and compliance risk assessments, education and training, and auditing and monitoring. Responsible for facilitating the development and maintenance of the Compliance and Privacy Work Plan. Works collectively with hospital management and other personnel to ensure that Corporate Compliance and Privacy Program initiatives are implemented across UMMS.

Principal Responsibilities and Tasks

The following statements describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Accountable for the Compliance Program at Member Organizations (MOs). Directs assigned MO-specific risk assessments related to HIPAA and privacy compliance. Conducts risk assessment analysis identifying high, medium, and low risks. Works with UMMS System and Physician Compliance Leadership to compile Executive reports on Member Organizations' aggregate risk assessment findings and recommendations. Communicates risks to both technical and non-technical stakeholders.

2. Lead assigned Member Organization Privacy Monitoring Program and ensure ongoing monitoring of inappropriate/unauthorized access and disclosures through the use of electronic record monitoring applications and features (e.g., Protenus, Break-the-Glass, etc.) and data loss prevention applications in accordance with the Health Information Technology for Economic and Clinical Health Act and HIPAA Privacy Rule. Perform trend analyses. Prepare summary reports for Executive Leadership on privacy monitoring activities.

3. Serves as an expert resource in interpreting and providing guidance to departmental representatives on developing policies specific to their departmental needs.

4. Oversees development and dissemination of compliance policies and procedures.

5. Leads the development and approves use of monitoring and auditing tools for assigned areas. Reviews reporting to ensure adherence to compliance and privacy. Recommends actions based on self-monitoring results to ensure that programs and procedures follow regulatory requirements.

6. Directs local compliance and privacy auditing and monitoring activities. Reviews findings as required for compliance with various regulatory guidelines. Identifies and escalates issues to executive leadership. Ensure compliance monitoring reports are updated.

7. Accountable for assuring timely completion of all management action plans resulting from compliance-related findings by internal audit for assigned MOs.

8. Provides ongoing compliance and privacy education including regular training sessions and special topic training.

9. Develops activities to foster compliance and privacy awareness through various modes of publicity (publications, newsletters, fairs, Intranet, etc.).

10. Maintains local systems to solicit, evaluate and respond to complaints, problems, and issues through all means of communication. Coordinates and oversees investigations, responses to violations, and corrective actions for reports of alleged fraud and noncompliance.

11. Ensures all escalated complaints for supported MOs are are resolved timely and satisfactorily.

12. Based on investigation report findings, reviews recommendations and approves adjustments necessary for achieving set objectives.

13. Utilizes IT systems/tools in managing and coordinating data investigations.

14. Participates in UMMS and Member Organizations' Compliance Committees as the lead compliance and privacy representative. Sets compliance committee agenda. Chairs the assigned Member Organization quarterly compliance committee and ensures the meeting packet is complete and submitted to stakeholders within five calendar days before the meeting.

15. Monitors and keeps up-to-date with laws, regulations, standards, and guidelines. Communicates and distributes information relating to updates to the appropriate stakeholders.

16. Prepares reports to meet the needs of local and Corporate executive leadership and the Audit and Compliance Committee of the Board of Directors.

17. Collaborates with the Director, Physician and Ambulatory Network for pertinent physician-related matters.

18. Perform other duties as assigned.

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women's and children's health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you'll enjoy as a member of our team.

LEADERSHIP COMPETENCIES

Regional Director Competencies

Professional Knowledge/Expertise

* Advances job competence and expertise by advancing leadership, interpersonal, professional, and technical competencies as best practices indicate.

* Participates actively in learning new activities and quickly applies acquired knowledge. Participates in professional activities that enhance skills, knowledge, and abilities. Networks effectively and strives to achieve certifications and advanced degrees where appropriate.

* Serves as a respected coach, teacher, and mentor by demonstrating 2-way communication and effective interpersonal skills. Coaches, teaches, and mentors staff using effective approaches for adult learning. Displays high levels of emotional intelligence.

* Creates a motivational climate that values diversity and encourages shared learning; creates a climate that inspires employees to work at their highest potential. Values diversity and supports that lead to the well-being and satisfaction of employees. Is non-defensive, open to feedback and receptive to learning new ideas.

Resource Management

* Actions support the optimal use of resources and property

* Exercises sound financial judgment. Develops contingency plans to address evolving financial issues;

quickly adapts to changing economic conditions by considering costs, benefits, and overall value of

work efforts. Manages within budget limits; effectively balances resources (i.e., human, technology,

and money)

* Promotes cost containment, savings and/or revenue opportunities. Minimizes expenditures by

seeking non-to-low-cost alternatives

* Manages risk; protects financial resources by creating a safe and accident-free environment

* Ensures responsible use of equipment and property; holds self and employees accountable for the

responsible use of company-owned property and equipment

Process Improvement and Capacity Building

* Leads, facilitates, and participates in efforts that result in effective strategic planning and continuous quality improvement. Quickly adapts to change, effectively manages transitions, and develops new solutions for addressing evolving challenges.

* Creates strategic and operational business plans; utilizes contemporary principles of strategicplanning. Develops meaningful outcomes and performance measures and monitor progress. Aligns goals; Produce results.

* Engages staff in Continuous Quality Improvement (CQI) activities; identifies key processes to ensure they meet customer requirements. Facilitates process improvement activities by effectively using CQI processes and tools.

* Quickly adapts to change and manages effective transitions. Implements and sustains change efforts, manages transitions effectively, and seeks new ways to meet evolving challenges.

* Promotes effective problem-solving efforts and encourages new ideas. Promotes efforts that successfully engage employees in effective problem-solving and decision-making practices. Leads others and holds self accountable for generating new ideas that contribute to cost-savings, increased efficiency, and improved effectiveness.

Values and Ethics

* Demonstrates respect for people and values

* Maintains a respectful, diverse, and inclusive work environment where decisions and transactions are transparent and objective

* Holds themselves, their employees, and their organizations accountable for their actions

Strategic Thinking

* Offers advice and creates plans based on analysis of issues and trends and how these link to the responsibilities, capabilities, and potential of FPI

* Scans an ever-changing, complex environment in anticipation of emerging crises and opportunities

* Develops well-informed advice and strategies that are sensitive to the various needs of multiple stakeholders and partners, reflect the strategic direction of the department and position the organization for success

Engagement (People, Organizations, Partners)

* Engages people, organizations, and partners in developing goals, executing plans, and delivering results. Mobilize teams, building momentum to get things done by communicating clearly and consistently, investing time and energy to engage the whole organization

* Use negotiation skills and adaptability to encourage recognition of joint concerns, collaboration, and to influence the success of outcomes

* Follow and lead across boundaries to engage broad-based stakeholders, partners, and customers in a shared agenda and strategy

Management Excellence (Action, People, Financial)

* Monitors employees' compliance with employee health requirements, workers' compensation, HR processes and other mandatory training and requirements to include holding employees accountable using progressive discipline as appropriate.

* Delivers results by maximizing organizational effectiveness and sustainability

* Ensure that people have the support and tools they need and that the workforce as a whole has the capacity and diversity to meet current and longer-term organizational objectives

* Align people, work, and systems with the business strategy to harmonize how they work and what they do.

* Conscientiously assign performance goals, offer year-round performance and feedback, and conduct timely performance, discussions, and reviews.

* Leads initiatives that result in the delivery of quality services across the organization; utilizes data to facilitate systematic improvement efforts.

Education and Experience

1. Bachelor's degree or an equivalent combination of education and experience is required. Master's degree preferred.

2. Ten 10 years of related compliance and privacy experience with a background in healthcare regulatory issues, including general familiarity with hospital billing, is required. Four (4) years of experience in healthcare or regulatory fields is preferred.

3. Certified in Healthcare Compliance or other professional compliance certification (or achieve certification by 12 months from hire date.)

4. Experience and working knowledge of Corporate Compliance, Audit, Legal, Privacy, or Information Security. Experience with case investigations management and compliance hotline management preferred.

Knowledge, Skills, and Abilities

1. Current knowledge of healthcare regulatory and compliance issues. Proven organizational skills and administrative ability is required.

2. Highly effective verbal and written communication skills are necessary to communicate and work effectively with all levels of staff and management.

3. Knowledge and ability to understand procedures, practices and policies in the assigned department and for the medical system.

4. Flexibility and the ability to adapt to shifting priorities, to work independently as we as part of a team. Must be self-motivated an able to evaluate the scope of each day's work and use time management and organizational skills to accomplish assignment.

5. Knowledge of personal computer operation and Microsoft Office applications. Experience with governance, risk, and compliance (GRC), audit, compliance, or other business intelligence based software preferred.

6. Ability to gather and analyze data and reports. Must have strong analytical and problem solving skills.

7. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.

8. Must be able to maintain confidentiality of all compliance related or other reported issues.

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