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Years of Experience
Date Last Verified
General Counsel, Compliance and Privacy Officer Duties: Leads and manages the legal affairs as well as the risk management, regulatory, licensure, compliance and privacy functions. Responsible for providing counsel on legal implications and considerations relative to business practices and organizational strategies and monitors and advises on legal trends and issues which must be taken into account with organizational decision making. Provides interpretation and advises on adherence to applicable laws, rules and regulations. Provide internal expertise in interpretation of regulatory guidance for applications and submissions for licensure, designations and operating under NYS Health Law. Provide oversight for organizational compliance and risk management. Serve as an internal resource for executive and department leaders to ensure programmatic compliance and risk management, in our increasingly complex healthcare environment. Provides legal advice and support to executive leadership and the Board of Directors including legal implications and considerations relative to business practices, organizational strategies and legal trends. Understands strategic initiatives and business needs; provides legal and organizational counsel on issues which must be taken into account when decisions are made. Advises the organization on litigation and other risks of business decisions and provides preventive counsel. Provides legal advice to ensure adherence to applicable laws, rules and regulations governing the organization. Provides oversight and management of general legal matters to support the organization including but not limited to review, drafting, negotiation, and finalization of contracts, licenses, consulting agreements, service agreements, joint ventures, strategic alliances/MOUs, compliance and employment matters. Consults with outside counsel on matters requiring areas of specialty (e.g. Employment law, FQHC regulations). In coordination with other executive leaders, develop, implement and maintain legal policies, procedures and practices as well as related training. Creates and maintains centralized resource for information on health care law and regulations that impact the organization and stays abreast of changes and trends. Oversees risk management framework that supports the organization. Communicates and provides support and education on risk management practices and outcomes. In conjunction with all levels of leadership and process participants, identify areas of organizational risk and mitigation strategies. Provides oversight and support to the Compliance Team in the development and maintenance of an effective audit program developed from the identified regulatory and risk strategies. Perform an annual assessment of the organizations entity-level controls including governance practices and present annual best practices benchmark report to the CEO. Oversee the coordination of the annual insurance policy review and renewal processes. Serves as Compliance Officer and provides regular reports to the CEO and Board of Directors. Manages organizational and regulatory compliance oversight to ensure independent assessment of organization functions and governance. Develops and maintains the organization Compliance Plan as well as compliance policies and procedures. In collaboration with the executive team, organize delivery of programs that increase compliance awareness, leadership and investigation of non-compliance. Manages the Compliance Committee ensuring follow up on findings and corrective actions. Oversees the process to identify potential areas of compliance vulnerability; responds to violations or investigations, works with appropriate leaders to develop and implement corrective action plans for resolution and provides guidance to prevent future issues. Provide regulatory review of materials and written responses related to any violations. Ensure organizational compliance with all Designations, Certifications and Accreditations. Serves as Organization’s Privacy Officer. Develops, implements and maintains agency wide Privacy and Confidentiality policies and associated procedures, forms and HIPAA records filing system in accordance with article 27-F and HIPPA Laws. Establishes and oversees a process to monitor all standards and practices related to privacy and confidentiality including but not limited to requests for an accounting of disclosures in accordance with the organizations procedure for disclosure accounting and proved oversight and management of the response, implementing appropriate safeguards for protection from intentional or unintentional unauthorized uses and disclosures of PHI, oversight to patient requests related to PHI as well as requests related to deceased individuals, and cooperate with any privacy investigation by the NYS Department of Health, Department of Health and Human Services, Office of Civil Rights or the NYS Division of Human, and investigates, addresses and responds to all privacy and confidentiality issues or breaches and mitigates the effects of any unauthorized use or disclosure of PHI or other privacy and security violations. Provides oversight to the publishing, maintenance and documentation that all patients receive Notice of Privacy Practices. Review Maintain current knowledge and application of regulatory changes. Ensure that records are retained in accordance with the organization’s records retention procedure. Ensure workforce training and awareness programs in HIPAA Privacy and Security requirements in accordance with the organization’s workforce training procedure. Routinely evaluate security and audit processes. Keep triggering events chart (HIPAA Ready Reference) up to date. Provide direct supervision to the Compliance Director and provide leadership to the compliance team to support the development and execution of the compliance and privacy strategy. Promote a culture of high performance and continuous improvement that values learning and a commitment to quality. Mentor and develop staff using a supportive and collaborative approach on a consistent basis. Establish and monitor staff performance and development goals, assign accountabilities, set objectives, establish priorities, conduct annual performance appraisals, and administer salary adjustment.
Qualification and Experience
Qualifications: JD Degree is required. An additional advanced degree Health Care Administration, Business Administration or related field is preferred. Requires a license to practice in New York State. Healthcare experience in a law firm or in-house is required, clinical experience is a plus. 8+ years relevant experience required, 10-12 years preferred. Must have 6+ years’ experience in management/supervision. Substantial experience representing Health Systems or Community based Health Center. Thorough understanding of the major Federal and State laws and regulations that govern non-profit health care providers. Proven track record of strong negotiation, communication, organizational and people management skills and the ability to influence, collaborate and build relationships. Experience negotiation and documenting complex transactions, including mergers, acquisitions, joint ventures and affiliations. Experience with compliance related issues and the management or oversight of litigation. Experience providing strategic, business and legal counsel to executive management. Proficiency in MS Office. Excellent judgment and creative problem solving skills, including negotiation and conflict resolution skills. Excellent communication skills, both written and oral; excellent interpersonal relations and ability to influence negotiations and resolutions. Superior management skills; ability to influence and engage direct and indirect reports and peers and in building, mentoring, and coaching a team of staff specialists. Stature, gravitas, and confidence to gain the credibility and respect of high-performing Board of Directors. Ability to make decisions in a changing environment and anticipate future needs. Requires the ability and commitment to respect and support inclusiveness and diversity including individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc. Requires individual demonstration of commitment to the behaviors and business impacts as well as modeling them in the organization. Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information. Employees are accountable for meeting the performance standards of their departments and must participate as requested in process improvement and quality improvement plans.
Company infoSherry Thomas