MAJOR ACCOUNTABILITIES/CRITICAL RESPONSIBILITIES
Conduct training activities, privacy audits, and monitors all electronic medical record activity for the health system.
Serve as HIPAA privacy resource for organization, assists workforce with HIPAA compliance and privacy policies and procedures.
Routinely monitor changes in the applicable HIPAA government regulations. Research and analyze available sources of regulatory guidance in response to specific questions.
Reviews FairWarning reports routinely to identify potential policy violations and investigates all questionable access;
Manage the progress of corrective action plans for conducted audits.
Maintain database of privacy investigations in accordance with Hospital policy and regulatory requirement.
Develop and provide all education for new and existing Stamford Health employees on privacy risk issues, the organization's Privacy program; and develop training materials to address privacy compliance risks.
Conduct privacy audits and rounding. Visits floors, patient rooms as requested, SHMG offices to discuss privacy policies/procedures, patient complaints, and ensure HIPAA compliance.
Conduct privacy investigations and in- person interviews with workforce members of all levels and backgrounds in coordination with Human Resources and applicable department leaders. Gathers necessary information pre/post interview and maintains complete discretion during investigatory process.
Manage challenging patient and employee encounters, both in person and via telephone. Exemplify Stamford Health core values in these interactions to protect patients, the organization, and ensure compliance with applicable laws and internal policies and procedures.
Prepare and/or develop written documentation such as policies, procedures, and other written communication to support ongoing activities of the Privacy program.
Demonstrate excellent judgment in escalating high risk matters to the Privacy Officer, General Counsel, Human Resources or other leaders as needed.
Develop and update annual work plan, conduct annual risk assessments in collaboration with Compliance, identifies and addresses high risk areas.
Manage the HIPAA Privacy Oversight Committee meetings and meeting preparation; develop and present various presentations to the Corporate Compliance Committee and Audit Committee.
Participate in Enterprise Risk Management Committee, SHMG IT Steering Committee, and IT Governance Committee
Collaborate with CISO on protecting patient privacy, breach mitigation and organizational training
Manage and train temporary or junior privacy staff
Work with outside counsel to draft breach notifications to Office of Civil Rights and State Attorneys General; compile and file annual privacy breach reports to Office of Civil Rights
Collaborate with Risk Management team on investigations and privacy issues, provide coverage to Compliance team as needed
Research, analyze and develop reports and correspondence in response to privacy complaints and incidents.
Develop and review HIPAA internal Intranet site
Present reports of HIPAA compliance activities to departments and various committees in the organization
Participate in professional organizations, represent Stamford Health in a positive light, collaborate with external resources to identify and develop improvements for the Compliance Program specific to Privacy.
Perform other related duties as assigned or requested in order to maintain a high level of service.
Required Skills
COMPETENCIES AND WORK EXPERIENCE REQUIREMENTS:
EDUCATION REQUIREMENTS (INCLUDE LICENSE, REGISTRATION, CERTIFICATION):