Compliance Analyst

The Compliance Analyst is responsible for Nashville General Hospital’s privacy program, including, but not limited to, the daily operations of the program, developing, implementing, and maintaining policies and procedures, measuring the program’s effectiveness, investigating and tracking incidents and breaches, and ensuring compliance with applicable privacy federal and state laws.  To include supporting the management and monitoring of key performance indicators (KPIs), position control, budgeting, financial planning, and the revenue cycle. The Compliance Officer ensures alignment with internal policies and external regulatory requirements to enable data-driven and strategic decision-making across the hospital’s financial operations.

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

• Assists with the implementation and maintenance of the policies and procedures and annual work plans for the hospital.
• Organizes and presents at the Internal Compliance Committee meetings
• Resolves associate concerns about legal and/or compliance questions
• Delivers or ensures delivery of the privacy training and orientation to all Associates, volunteers, and medical and professional staff, and applicable business associates
• Reviews all business associate agreements to determine that all privacy concerns, requirements, and responsibilities are addressed
• Works with Privacy Officer to establishes and maintains a mechanism to track access to protected health information (PHI) within the hospital and as required by law, and allows qualified individuals to review or receive a report on their activity
• Works with all employees involved with any aspect of the release of PHI to ensure full coordination and cooperation under the legal requirements and the entities’ policies and procedures
• Advises the management team on the hospital’s compliance with laws and regulations 
• Initiates, facilitates, and promotes activities to foster privacy awareness within the organization and related entities
• Maintains the process for receiving, documenting, tracking, investigating, and resolving all complaints concerning the organization’s privacy concerns and any other issues that may be reported. Also, maintains all required breach determinations and notification processes under HIPAA and applicable state breach rules and requirements
• Works with the Chief Compliance Officer and legal counsel to file required reports on breaches of privacy, should they occur
• Collaborates with the Director of Information Security to ensure alignment with the privacy and security compliance programs including policies, practices, investigations, and acts as liaison to the information systems department.
• Collaborates and assists the CFO in monitoring and analyzing financial KPIs to evaluate the hospital’s performance against strategic goals.
• Supports coordination of position control meeting to ensure staffing levels align with budgetary constraints and operational needs. Collaborates with finance, human resources, and department leaders to review staffing requests and ensure adherence to approved position control guidelines.
• Analyzes revenue cycle operations to identify opportunities for efficiency, cost savings, and increased reimbursement.
• Collaborates with the Privacy Officer to ensure alignment with HIPAA policies, targeted training as needed and compliance orientation training.
• Participates in strategic planning initiatives by providing data-driven insights and financial forecasts.
• Facilitates the Ethics and Compliance meetings 
• Performs or oversees initial and periodic information privacy risk assessment/analysis, mitigation, and remediation
• Ensures that the organization maintains appropriate privacy and confidentiality consents, authorization forms, and Notice of Privacy Practices (NPP) forms
• Cooperates with the U.S. Department of Health and Human Service’s Office of Civil Rights or other legal entities in any compliance reviews or investigations, and
• Maintains current knowledge of applicable federal and state privacy laws and monitors advancements in information privacy technologies to ensure Nashville General Hospital complies with new requirements.
• Prepare and present clear, financial reports and dashboards to senior leadership
• Any other duties as assigned.

QUALIFICATIONS: 

 

• Working knowledge of healthcare privacy laws and regulations
• Excellent written and oral communication skills 
• Excellent analytical, organizational, and problem-solving skills
• High level of displaying integrity and confidentiality
• Strong interpersonal skills and problem-solving skills
• Computer skills: Competency with Word, Excel, PowerPoint and business intelligence tools.
• Experience with PolicyTech, Intelligent Contracts, or Ethicos software is helpful
• Healthcare certification is desirable
• Experience with position control processes and workforce planning

EDUCATION/ EXPERIENCE: 

 

• Baccalaureate degree required in Healthcare Administration, Health Information Management or a related health care field or higher,
• Minimum of three years of analytics experience with state and federal information privacy laws, including but not limited to Health Information Portability and Accountability Act (HIPAA) as amended, healthcare finance, or operations.