**Hours of Work :** 8am - 5pm **Days Of Week :** Monday - Friday **Work Shift :** 8X5 Day (United States of America) **Job Description :** **Assistant General Counsel – Compliance and Privacy** **POSITION OVERVIEW.** Under the direction of the MHS Chief Legal Officer/Chief Compliance Officer (CLO/CCO), the attorney selected for this position leads the seven core elements of the MHS compliance program and the privacy program. Primary duties include responsibility for system level and entity level annual compliance work plans, performance dashboards, reports to management, and collaboration with entity compliance officers, and along with the CLO/CCO, routine reports to the MHS Board and the MHS Board Committee charged with corporate oversight for the system. **POSITION RESPONSIBILITIES.** **_Essential Functions._** Maintain the effectiveness of the MHS compliance and privacy program core processes including: + Creation and revision of compliance and privacy program policies under the direction of the CLO/CCO. + Evaluation of periodic risk assessments to identify high risk areas. + Formulation of annual MHS system level compliance work plan focused on continuous improvement of processes in identified risk areas. + Provide input, review and approve entity level annual compliance work plans. + Carry out the MHS annual conflicts of interest disclosure process. + With the CLO/CCO, attend system and entity level Board meetings to maintain communication and updates. Assist the CLO/CCO with agendas and meetings of the Audit & Corporate Oversight Committee and the Corporate Compliance Committee. + Collaborate with entity compliance officers, monitor progress in accordance with dashboards, completion of annual work plans and responsiveness to MHS compliance program activities. + Oversee the MHS employee, vendor, contractor and medical staff screening processes that prohibit employment or contracting with individuals or companies excluded from federally funded programs. + Develop and deploy effective communication and education regarding MHS business ethics and compliance and privacy requirements. **_Programing and Reporting_** + Develop and deploy a multi-faceted educational program that focuses on the elements of the MHS compliance and privacy programs for new and existing workforce members, including certain independent contractors. + Develop and deploy education focused on identified business processes to mitigate the risk of noncompliance in areas vulnerable to error or noncompliance such as billing, coding, Stark laws, fraud & abuse laws, false claims, patient privacy, or other identified risk areas. + Develop and deploy effective communication throughout MHS to maintain high employee awareness of the MHS compliance and privacy programs, including how to raise and address concerns without fear of retaliation. + Oversee the MHS reporting mechanisms, investigation and follow-up of reports of compliance and patient privacy violations, misconduct, questions or concerns including: + Operation of the MHS Compliance Hotline, HIPAA Hotline, and Business Ethics Hotline + Oversight and independent investigation of matters related to compliance and/or response to reports of possible compliance issues. See that matters are resolved and corrective action taken as warranted keeping the CLO/CCO informed as appropriate. + Leading MHS’s Privacy Program, including but not limited to, development, implementation and maintenance of Privacy strategies, policies and procedures, training, investigation and tracking of privacy incidents and reporting inappropriate access and/or disclosure of protected health information according to HIPAA, HITECH and applicable state/federal laws + Working with representatives from the Human Resource Department with regard to disciplinary measures arising from violations of system HIPAA and patient privacy policies. + Functioning as the point person within the Office of Legal Affairs to partner with MHS’s IT Department as to MHS’s data protection programs, including third party access process. + Oversight and independent investigation and responses to Office of Civil Rights and HIPAA complaints, and as necessary, responds to complaints and files required reports to management and/or regulatory bodies. + Coordination with the CLO/CCO and attorneys in the Office of Legal Affairs on any review or investigation that is non-routine and/or appears to create risk for MHS. + Participation in evaluation of internal controls to see that processes are in place capable of detecting significant instances or patterns of unethical conduct by employees, agents or contractors. + Maintenance of an incident tracking system and prepare reports for management and MHS Boards. + Serve as a consultant to entity compliance officers with respect to incidents that may arise at the entity level requiring investigation, follow-up and resolution. + Assist the MHS CLO/CCO in responding to inquiries or investigations from external agencies. Perform research, serve as an internal consultant and provide guidance on business ethics and compliance matters to employees and management, including the business office, coding, physician contracting, fraud & abuse laws, Medicare/Medicaid regulatory requirements, privacy, or other compliance related subject matters. + Monitor MHS processes designed to meet regulatory requirements related to refunding overpayments and coordinate with the Central Business Office and others as needed. + Implement processes to monitor regulatory updates, new laws and stay abreast of healthcare regulatory requirements, and as needed, communicate to affected areas. + Participate in workgroups and other forums to provide compliance and privacy expertise and serve as the point person within the Office of Legal Affairs to support MHS initiatives as needed. + Work with MHS Governmental Activities personnel as needed on emerging legislation, comments to proposed regulations, etc. + Implement and oversee activities designed to monitor high risk areas such as coding, billing, physician contracting, screening of employees and contractors and other areas vulnerable to compliance risk: + Confirm that periodic coding compliance reviews are performed, review reports and corrective action plans are developed and implemented. + Implement compliance monitoring activities in coordination with other areas such as Finance, Central Business Office, Revenue Cycle, Health Information Management or other functional areas with high risk areas. + Other duties as assigned **EDUCATIONAL AND EXPERIENCE REQUIREMENTS.** + Minimum ten (10) years’ experience in healthcare operations or compliance, preferably with a large, multi-faceted healthcare company. + Experience with information privacy and security-related activities such as investigations and reporting, auditing, and monitoring, education and training, risk assessments and mitigation/remediation procedures. + Experience with interpreting state and federal requirements applicable to the organization, assessing their impact and making recommendations to operational stakeholders to ensure compliance. + Excellent assessment, communication, organization and teaching skills + This position is a full time position working at MHS’s Corporate Office in Dallas and in keeping with the remote work policy of the system and the Office of Legal Affairs. + Certifications (or in the process of obtaining): + Healthcare Privacy Compliance (CHPC) + Information Privacy Professional/United States (CIPP/US) + Healthcare Privacy and Security (CHPS) + Healthcare Compliance (CHC) **Minimum Job Qualifications:** + Bachelors Degree and Juris Doctor (J.D.); an active license to practice (Texas license or ability to apply for and obtain Texas license); and a minimum of 10 years’ of relevant health law experience in a law firm practice and/or in-house is required. Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by _Modern Healthcare_ , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned: + Magnet® designations for Methodist Dallas, Methodist Charlton, Methodist Mansfield, and Methodist Richardson Medical Centers + 150 Top Places to Work in Healthcare by _Becker’s Hospital Review_ , 2023 + Top 10 Military Friendly® Employer, Gold Designation, 2023 + Top 10 Military Spouse Friendly® Employer, 2023 Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by _Modern Healthcare_ , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned: + Magnet® designations for Methodist Dallas, Methodist Charlton, Methodist Mansfield, and Methodist Richardson Medical Centers + 150 Top Places to Work in Healthcare by _Becker’s Hospital Review_ , 2023 + Top 10 Military Friendly® Employer, Gold Designation, 2023 + Top 10 Military Spouse Friendly® Employer, 2023 Equal Opportunity Employer It is the policy of Methodist Health System (MHS) to select, develop, and promote employees based on individual ability and job performance. It has been, and will continue to be, the policy of MHS to provide equal employment opportunity to all people in all aspects of employer-employee relations without discrimination because of race, color, religion, national origin, age, sex, sexual orientation, gender expression, disability, marital status, genetic information or ancestry. This policy affects decisions including, but not limited to, an employee’s compensation, benefits, terms and conditions of employment, opportunities for promotion, training, development, transfer all other privileges of employment. MHS is committed to maintain a working environment free of intimidation, workplace discrimination and harassment. Retaliation or attempted retaliatory behavior that occurs as a result of an employee’s exercise of their rights under this policy or any other statutorily protected right is strictly prohibited and will be grounds for disciplinary action.