Compliance and Privacy Coordinator Summary Responsibilities:
The Compliance & Privacy Coordinator serves the organization as the subject matter expert on accreditation, quality, and other clinical regulations and requirements. Management and oversight of the credentialing team and processes are also key components of the duties, as are the investigatory and leadership skills needed to assist with the management of the Compliance and Privacy functions of the enterprise.
Compliance and Privacy Coordinator
- Seeks, maintains, and shares working knowledge of applicable healthcare quality and clinical practices, certifications, accreditations, industry regulations and guidelines (e.g., evidence-based medicine, regulatory requirements for healthcare utilization management and claims processing, peer review laws, professional scope of practice requirements, and/or applicable agency rules).
- Stays up-to-date on healthcare quality & clinical practices to inform and assure implementation, and follow up with responsible work areas on execution of performance metrics and accreditation requirements for Credentialing Verification Organization, Health Plan, Utilization Management, and other applicable accreditation or certification standards.
- Understands health plan products, functions, and policies & procedures, and their relationship with Company's accreditations and certifications (e.g., health plans receiving credit for accreditation components delegated to Company).
- Assists in the development and implementation of Company's Quality & Accreditation strategies and goals, and the overall delivery of Company's Quality Management Program.
- Assures that applicable certification and/or accreditation standards are met and maintained by Company.
- Collaborate with leaders and applicable colleagues (e.g., compliance, legal, operations, etc.) on cross-functional, coordinated efforts for quality improvement, preparation for surveys, and internal and external (e.g., third party) audits, assessments or reviews.
- Provide leadership and maintain oversight of Quality Improvement (QI) processes for accredited programs.
- Organize and facilitate QI internal reviews and training to educate and assure quality and corporate compliance. Based on findings, make recommendations for process improvement
- Represents Company at meetings with customers, potential customers, and accrediting bodies (e.g., National Committee for Quality Assurance (NCQA) and URAC on quality and accreditation related topics, in a transparent manner that demonstrates Company's commitment to processes and programs designed to deliver quality products and services, a continued desire to improve quality, satisfy accreditation requirements, and maintain accreditation.
- Leads health care quality projects and initiatives for the enterprise.
- Assimilates information to proactively develop quality activities aligned with company strategies and values. Links the quality management activities to business goals.
- Serves as lead resource and subject matter expert (SME) on the quality program to develop and influence business strategies, including forming and leading cross-functional teams to assist business units in integrating quality into their strategic and operational plans.
- Evaluates the organization's policies, procedures, and work instructions to meet business and Accreditation needs.
- Responsible for URAC and NCQA compliance, including preparatory and actual audits
- Responsible for the management and oversight of the provider credentialing and re-credentialing team and processes, to ensure NCQA compliance.
- Participate in Credentialing Committee meetings, as necessary.
- Responsible for oversight of third-party vendor(s) who may assist with functions associated with the credentialing processes.
- Responsible for ensuring credentialing policies and work instructions meet contractual, regulatory, and accreditation standards.
- Manage team performance to operational success and foster professional development.
- Collaborates with stakeholders to combine scientific knowledge with a focus on customer service and compassion for the members we serve.
- Gathers and communicates the application of evidenced-based medicine to influence processes, policies, strategy development, and tactical planning.
- Develops and maintains clinical expertise related to scope of services through review of scientific journals, recent data disclosures, and personal development
- Reviews and investigates privacy complaints, concerns or incidents received within the enterprise.
- Assists with advising, training, and managing HIPAA, HITECH, and other privacy matters or inquiries received within the enterprise.
- Assists with oversight of applicable laws and regulations, including, HIPAA, HITECH, state privacy laws, and privacy-related contractual obligations.
- Assists with maintaining and updating the enterprise privacy policies and procedures.
- Prepares effective communications concerning the compliance function/program and the workforce.
- Manages the monthly exclusion verifications, as required by federal law and/or contractual obligations.
- Responds to compliance inquiries (questionnaires, audits/assessments, reviews, general inquiries, etc.)
- Updates and manages the annual compliance training for the enterprise
- Investigates and responds to compliance hotline or web inquiries, complaints or allegations, as requested.
- Drafts, updates, and/or maintains compliance policies and procedures.
- Bachelor's degree in nursing preferred. Additional direct experience will be considered in lieu of degree.
- 5+ years' experience in the field of health care accreditation, quality management, or compliance.
- Highly effective and active communicator. Initiates personal contacts with others. Perceived by others as both approachable and accessible, with a strong work ethic.
- Knowledgeable of how decisions impact all aspects of the business. Approaches his/her work as an interconnected system.
- Strong business acumen, intelligence and capacity; thinks strategically and implements tactically. Able to drive toward achievement and effectively execute a business plan.
- Strong leadership and interpersonal relationship skills. Able to lead successful cross-functional efforts.
- Ability to position the organization for the future, looking beyond the present situation to conceptualize key trends and identify changing market demands.
- Team player, with self-confidence, honesty, and a high degree of integrity
- Strong analytical and decision-making skills.
- Excellent planning and problem-solving skills; information and detail oriented.
- Able to travel for business purposes, if needed.
Eight Eleven Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, national origin, age, sex, citizenship, disability, genetic information, gender, sexual orientation, gender identity, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state, and local laws.