Northern Light Health Department: Compliance Position is located: Northern Light Home Care & Hospice So Portland Work Type: Part Time Eligible Hours Per Week: 20.00 Work Schedule: Variable Summary: The Compliance & Privacy Officer is responsible for the development, implementation, and maintenance of the Agency's Compliance program to assure compliance with internal policies and procedures and all applicable federal and state health care laws and regulations. The incumbent promotes quality and provides service, assistance and guidance to Agency staff on all manner of compliance and privacy related matters; develops and reviews compliance/privacy policies and procedures; creates and implements compliance/privacy education; identifies potential areas of vulnerability and risk; and develops, implements and monitors corrective action plans to resolve instances of conduct that do not conform to Northern Light Health/Agency policies or to federal or state laws or regulations. The Compliance & Privacy Officer is accountable to the President of the Agency to ensure that compliance activities are implemented across the Agency. The incumbent acts as a mentor for leadership team members in the investigation of all potential HIPAA disclosures and assesses if a breach has occurred. The Compliance & Privacy Officer educates leadership and staff on the appropriate reporting methods including timeliness and content of documentation. The incumbent produces and analyzes statistical information, reporting and makes recommendations that are in alignment with all State and Federal Regulations. The Compliance & Privacy Officer serves as the Agency resource at the System Level for Compliance and Privacy activities. Additionally, the incumbent promotes an awareness and understanding of positive ethical and moral principles consistent with the mission and values. The Compliance & Privacy Officer provides regular reports to the Quality and Professional Advisory Committee of the Board of Directors. The incumbent works collaboratively with all internal and external customers to attain the highest levels of customer service and clinical excellence. Performance reflects the mission and values of Northern Light Home Care and Hospice. Responsibilities: 1. Compliance & Privacy Promotes and maintains an environment that fosters compliance with all accreditation, regulatory, certification requirements and organizational policies and procedures. • Manages the agency Compliance & Privacy programs. • Serves as a role model and mentor for compliant behavior consistent with the NLH Mission, Vision, Values and Brand Standards. • Acts as the internal authority on relevant compliance/privacy laws and regulations, including developments that may affect the Agency. • Ensures compliance with HIPAA privacy regulations and Maine privacy laws. • Works closely with the Information Security on HIPAA security issues, as needed. • Performs ongoing risk assessments and audits to ensure HIPAA compliance. • Assists with the development, implementation, maintenance, and revision of compliance and privacy policies and procedures. • Develops and maintains an annual Compliance Work Plan for the Agency consistent with HHS OIG compliance program guidance, the annual HHS OIG Work Plan, emergent state and federal regulatory issues, and internal risk assessment, including PEPPER reports.. Provides regular reports on execution against Work Plan to the Homecare Executive Leadership Team. • Develops, implements and maintains, and assures adherence to NLH privacy and information security policies and practices in compliance with federal and state laws, including required compliance activities around HIPAA Business Associate relationships and around privacy breach risk assessment and reporting. • Responds to NLH Internal Audit department requests for Agency access. Coordinates Management Responses to audit findings and recommendations. Manages Agency Internal Audit attestation process. • Documents activities in accordance with applicable laws, regulations, and NLH policies and procedures, including in the MediRegs Compliance Activity Reporting System (CARS). • Follows MediRegs for applicable State, Federal regulatory and OIG alerts and communicates to leadership, as appropriate. • Works with Human Resources personnel to ensure consistent enforcement of compliance requirements through appropriate disciplinary action. Assist to determine severity level to apply system directed sanctions. • Assures appropriate assessment and documentation of unauthorized disclosures in the HIPAA Disclosure Tracking database. Completes Privacy Officer breach assessment and summary of events. Attends the Homecare Executive Leadership Team (which acts as the Compliance Committee) meetings at least 4 times a year to provide appropriate reporting. • Investigates, resolves and documents all identified compliance-related deficiencies in accordance with applicable laws, regulations, and NLH and Agency standards, in conjunction with legal counsel as appropriate. • Provides leadership education, including orientation regarding event reporting, HIPAA database entries and manager investigations, and other Compliance/Privacy topics such as appropriate documentation, disclosure of personal health information. • Provides annual, in person compliance/privacy training to medical staff and the Board. • Publicizes the NLH compliance line reporting system (i.e. “Hotline”) whereby Agency employees and others can report compliance issues and concerns without fear of retaliation. • Responds to and appropriately documents all Hotline reports and non-Hotline compliance questions and concerns affecting the Agency and its operations. • Participates in NLH Compliance Task Force and/or State trade association committees as delegated by department leader. • Completes self-monitoring as assigned by the NLH Compliance Task Force. • Keeps Home Care & Hospice Executive Leadership team apprised of significant compliance & privacy developments. • Maintains current knowledge regarding emerging compliance/privacy risk areas and recommends new and/or changes to appropriate policies and procedures. • Evaluates “Open Payments” made to all employed physicians and mid-level providers, investigating and reporting out to executive team and Northern Light Compliance, as appropriate. • Oversees and ensures Stark audit completion. Reports instances of failing to pay providers at fair market value for further investigation. • Fair warning report: reviews and follows up regarding events of potential improper system access. • Evaluates, investigates findings and reports of monthly HIPAA walkthroughs by Safety Leads in each region. • Reviews annual conflict of interest submissions by leadership and board and investigates potential conflicts; provides summary to Board and Executive Leadership. • Functions in a clinical capacity (within the scope of professional license) in support of agency operations. 2. Community Outreach Participates in development, marketing, and outreach to promote Agency services. • Participates in marketing efforts. • Promotes a positive agency image in the community. • Works collaboratively with Northern Light Health affiliates to provide complimentary programs across the continuum. • Represents the Agency on Northern Light Health committees and workgroups as directed. • Participates in varied community-based advisory panels, councils, or coalitions as a Northern Light Home Care & Hospice representative. 3. Performs additional duties as required or assigned. Other Information: Competencies and Skills + Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed. + Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan. + Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation. + Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively. + Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit. + Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately. + Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level. + Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully. + Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved. + Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others' actions and decisions with and without express authority. + Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others. Education + Required Bachelor's Degree Working Conditions + Work with computers, typing, reading or writing. + Prolonged periods of sitting. Position Compliance & Privacy OfficerLocation Req ID null