Job description

Works with assigned Corporate Compliance Director(s), Legal, Health
Information Management and other key departments and committees to ensure
the organization maintains appropriate privacy and confidentiality consents, authorization
forms, notices, and materials reflecting current organizational practices and requirements.

Collaborates with each Affiliate’s HIM Director and other applicable staff to ensure
patients’ right to request access, amendment, accounting of disclosures, restrictions, and
confidential communications of protected health information when appropriate.

Ensures processes are in place at each entity to facilitate patient receipt of the Notice of
Privacy Practices in Affiliate’s registration areas, owned or operated physician
practices/clinics, and other business units.

Personally presents privacy training at each Affiliate’s new hire orientation.

Attends corporate-led educational events and regularly scheduled FPO Conference Calls/Webinars for HIPAA privacy topics.

Reports all Office for Civil Rights (“OCR”) correspondence or contacts for each entity
to the assigned CCD or the CCO immediately upon notice of such activity.

Communicates with the CCD upon discovery of any potential or alleged privacy incident,
complaint, or concern of noncompliance and works with the CCD to investigate the
matter until resolution is achieved.

Conducts investigations and assignments for all HIPAA privacy issues under the guidance of the assigned CCD, including completion of the Data Breach Risk Assessment, when indicated.

Enters all reported privacy complaints and incidents into the incident tracking system on a timely basis. Maintains timely and thorough documentation and status updates to ensure a complete record of the investigative steps taken as
directed by the CCD or CCO.

Reports all current and ongoing HIPAA privacy issues to the Facility Compliance
Committee in general terms.

Conducts regularly scheduled Data Privacy & Security Monthly Walkthrough assessments of various departments throughout each Affiliate’s facility and other business units to monitor adherence to privacy regulations and organizational policies and reports the results to the Facility Compliance Committee.

Promotes an environment where employees are encouraged to report instances of non-compliance with privacy regulations, policies, and/or procedures.

Reviews and coordinate communication, distribution, and implementation of new and revised privacy policies and procedures.

Coordinates with the Director of Information Systems to ensure HIPAA Security standards are implemented and maintained.

Audits and monitors user access activity of Electronic Health Record system(s) for user activity occurring outside the scope of a user’s authorized access and job duties.

Assists the Contract Administrator with determining whether a contract requires a Business Associate Agreement (“BAA”), and ensures facility-level BAAs are maintained in accordance with the Document and Record Retention Policy and Schedule and the Business Associate Agreement Requirements Policy.

Maintains an awareness of current privacy and confidentiality laws, statutes, and
regulations.

Serves as each Affiliate’s subject matter expert on privacy, including but not limited to privacy questions regarding law enforcement, news media, social media, substance use disorder treatment records (i.e. Part 2 records), etc., and consults the Corporate Compliance and Privacy Department, as needed.

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