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1. Manage day-to-day compliance operations, including oversight of investigations, incident response, privacy matters, and corrective action tracking.
2. Lead and/or supervise HIPAA privacy investigations, risk assessments, and required internal and external reporting.
3. Oversee the internal compliance incident reporting system, ensuring timely review, documentation, investigation, and follow-up of reported concerns.
4. Conduct compliance investigations and assessments in accordance with established policies, procedures, and protocols.
5. Analyze incident and investigation data to identify trends, emerging risks, and organizational compliance gaps, and recommend corrective actions.
6. Coordinate remedial actions and corrective measures in collaboration with departmental leadership and key stakeholders.
7. Assist the General Counsel/Director of Compliance with implementation, maintenance, and continuous improvement of the Compliance Program and related policies and procedures.
8. Support accreditation and regulatory compliance activities, including AAAHC, CARF, FTCA, and HRSA requirements.
9. Assist with the development and delivery of compliance education and training for staff and leadership, including partnering with the Compliance Specialist with new employee orientation.
10. Communicate effectively across all organizational levels regarding compliance issues, expectations, findings, and corrective actions.
11. Collaborate with Legal, Human Resources, IT, Health Information Management (HIM), Quality, and Safety teams to ensure coordinated compliance responses.
12. Participate as an active member of incident response, compliance, and related committees.
13. Prepare summaries, analyses, and reports for the General Counsel/Director of Compliance and organizational leadership, as requested.
14. Oversee maintenance of compliance calendars, tracking systems, and documentation.
15. Provide administrative or supervisory guidance to compliance support staff, as assigned.
