Facility Compliance and Privacy Officer - Regional Hospitals

Discover Vanderbilt Health: With eight hospitals and over 180 clinics, we are the region’s largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you’ll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.

Organization:

Compliance Operations - VUH

Job Summary:

The Facility Compliance and Privacy Officer (FCPO) is responsible for coordinating local compliance program activities at assigned local hospitals and their related departments. The FCPO works under the joint general direction of the Office of Compliance and Corporate Integrity (OCCI) and the VUMC Privacy Office (Privacy), with a strong dotted line to hospital leadership, to maintain and continuously promote compliance with VUMC policies and applicable regulations, prevent or detect potential violations of fraud, waste, abuse and privacy requirement improve effective compliance efforts consistent with approved program Work Plans. The FCPO serves as a key coordinating and standardization function for VUMC’s overall regulatory compliance work plans.

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KEY RESPONSIBILITIES

• Provides guidance to assigned facilities and related entities regarding the VUMC compliance program and policies and procedures to ensure adherence to applicable laws, regulations, and other governmental requirements. 
• Responsible for effective coordination of facility compliance efforts as laid out in VUMC’s compliance and privacy work plans or as otherwise assigned. Performs periodic walkthroughs, audits, or other monitoring to ensure compliance with VUMC regulatory policies and data privacy and security practices and to promote awareness of the VUMC compliance program and VUMC privacy practices and reinforce VUMC’s Speak Up expectations and non-retaliation policies for those who raise any concern; 
• Heads or staffs the Facility Compliance Committee following VUMC standards approved by the General Regulatory Compliance Committee; Prepare summary reports of committee activities and other local compliance and privacy efforts for presentation to the General Regulatory Compliance Committee, Information Privacy and Security Executive Committee, or other compliance and privacy oversight groups.
• Provides advice to facility’s executive leadership, directors, and staff on ethics and compliance and privacy concerns. Assists with interpreting and applying the Code of Conduct (Code), VUMC policies, and other regulatory requirements within their scope.
• Conducts investigations resulting from concerns raised to leadership, to OCCI and/or Privacy Office directly, or to the VUMC Integrity Line. Investigates compliance related concerns, including, but not limited to internal and external ethics cases, HIPAA/HITECH violations, controlled substance discrepancies, and ADA complaints, monitors physician relationships including contracting, payments, and expense reimbursement, and manages a portfolio of privacy-related inquiries, complaints, and concerns to ensure they are handled appropriately and in a timely manner.
• Identify any local trends related to compliance and privacy matters. Develop strategies to operationalize compliance with regulations and assists OCCI and Privacy Office with benchmarking local facility compliance efforts against applicable best practices;
• Assists in the resolution of major compliance related issues and/or compliance efforts. Alerts OCCI and Privacy immediately on urgent matters and coordinates local response to such matters.

TECHNICAL CAPABILITIES

• Computer/Electronic Knowledge: Knowledge of the use of applications and tasks on computers and other electronic devices as part of regular work responsibilities.  It includes knowledge of software such as word processors, spreadsheets, text editors, and graphics and experience with the electronic medical records (i.e., Epic) and EMR monitoring software.
• Knowledge- Maintain extensive and current knowledge of health care compliance in the areas of health care laws, regulations, processes, systems, documentation and billing, including requirements and regulations that pertain to the Medicare and Medicaid programs, the Physician Self-Referral (Stark) law, the federal Antikickback statute, the federal Civil False Claims Act and the HIPAA/HITECH privacy rules.  Demonstrates knowledge of the appropriate rules and regulations and apply them in difficult, stressful and complex situations. Able to interpret and explain rules and regulations that are ambiguous or unclear. Directs others in interpreting rules and regulations on the job and trains others in them.
• Documentation & Writing Skills (Advanced): Demonstrates knowledge, training, and experience in documentation and writing to provide high quality products that will engage an audience and speak for the organization. Delivers documentation services in a creative and imaginative manner while setting a standard for others.
• Project Management (Advanced): Planning, organizing, and managing resources to bring about the successful completion of specific project goals and objectives.  Demonstrated ability to plan, manage and work independently on multiple concurrent projects and initiatives.
• Data Analysis (Advanced): The ability to analyze data in an accurate manner.

Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.

At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.

Core Accountabilities:

Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in. Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others. Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas. Team Interaction: May lead mid-sized projects; coaches and guides team members.

Core Capabilities :

Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Service: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Position Qualifications:

Responsibilities:

Certifications:

Certification in Healthcare Privacy Compliance (CHPC) - Healthcare Compliance Association (HCCA)

Work Experience:

Relevant Work Experience

Experience Level:

7 years

Education:

Bachelor's (Required)

This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth.

Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity.  EOE/Vets/Disabled.