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POSITION SUMMARY: This position is a combined position to include Compliance, Integrity, Privacy and Risk Management for Saint Joseph's Health System (SJHS). In addition, position will have responsibility for managing all legal documents for SJHS. The Compliance Integrity and Privacy Manager (aka Compliance Integrity and Privacy Officer – CIPO) implements and oversees all components of the corporate compliance program at SJHS . CIPO effectively facilitates an ethical and compliant culture in SJHS’s healthcare delivery and business practices and works with Leadership Team to facilitate compliance goals and requirements; CIPO acts as resource staff to SJHS Board Compliance & Integrity Committee, providing all important and relevant information and advice. As appropriate to SJHS and to a Federally Qualified Health Center, CIPO provides leadership and direct responsibility in the following areas: annual compliance and privacy work plan; compliance education, compliance and privacy policies and procedures; investigation and resolution of compliance and privacy issues; management reporting (to SJHS Board and to Trinity Health); annual internal audit(s) in collaboration with staff and Trinity Health and as appropriate to SJHS and its entities; participation in risk assessment and management.

Additionally, the Privacy Officer (PO) serves as the internal subject matter expert on Health Insurance Portability and Accountability Act (HIPAA) and is responsible for ensuring privacy policies to protect the integrity of personal health information (PHI) are enforced. The Privacy Officer oversees initial and ongoing employee privacy training and develops HIPAA-compliant procedures where necessary. HIPAA risk assessments will be performed to evaluate SJHS’s existing policies and procedures for HIPAA compliance. The Privacy Officer will monitor compliance with the privacy program, investigate incidents in which a breach of PHI may have occurred, report breaches as necessary, and ensure patients rights in accordance with state and federal laws. In order to fulfil the duties of a Privacy Officer, the appointed person will develop, manage, and implement processes to ensure the organization’s compliance with applicable federal and state HIPAA regulations and guidelines, particularly regarding access to and use of PHI. All privacy related matters related to information systems will be coordinated with the Director of Information Systems as appropriate.

This position is also responsible for the oversight, implementation and maintenance of the Risk Management & Patient Safety Program across SJHS with the objectives of minimizing risk to patients, visitors, staff and physicians and reducing potential liability and litigation for SJHS. Oversees the day-to-day activities related to coordinating insurance coverage, assisting the local claims process, interfacing with outside legal counsel, administering the risk management plan on a day-to-day basis, managing and analyzing risk management data and directing risk management educational programs. Interfaces with Trinity Health's Insurance and Risk Management Services Department (IRMS) and will coordinate new and existing initiatives with Trinity Health as those initiatives are implemented with SJHS.

Will assist management with the coordination and control of all SJHS legal, policy and procedure documents. This would include proper facilitation with Trinity Health Legal Department as appropriate, assisting with the execution of legal documents and the appropriate development, storage and maintenance . Additionally, position will work with management and Trinity in the proper maintenance of all SJHS policies and procedures to be in compliance will all regulations and grant requirements.

EDUCATION REQUIREMENTS: Bachelor's degree required. Master's or other post-graduate degree in health services administration, clinical services, health care law, or related field of study is valued.

CERTIFICATION REQUIREMENTS: None

EXPERIENCE REQUIREMENTS: A minimum of five years of healthcare industry experience. Leadership role and participation in compliance program activities and/or risk management for a health system. Thorough understanding of HIPAA regulations and guidelines. Public relations, good communication and project management experience preferred.

JOB KNOWLEDGE: Broad knowledge of healthcare, compliance, government regulations and risk management. Understanding of risk assessment, audit and monitoring techniques, internal controls and facilitation of action plan implementation. Excellent communication, organizational, project management and computer skills required . Excellent customer service orientation with the ability to relate directly, openly and effectively with internal and external stakeholders at all levels of the organization .

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.