*TWCGME provides contracted support services to The Wright Center for Community Health pursuant to a Memorandum of Understanding. Therefore, oversight of support department services includes oversight of the provision of support services to The Wright Center for Community Health as well as TWCGME. 

OUR MISSION: 

To improve the health and welfare of our community through inclusive and responsive health services and the sustainable renewal of an inspired, competent workforce that is privileged to serve. 

OUR VISION: 

For our Graduate Medical Education Safety-Net Consortium framework that integrates patient care delivery, workforce development and innovation is the leading model of primary health care in America. 

OUR PASSIONATE PURPOSE: 

To demonstrate an “Achievable by All” Graduate Medical Education Safety-Net Consortium model that co-creates transformational healthcare teams of leaders who empower people, families and communities to own and optimize their health and healthcare delivery system. 

OUR CORE TARGET: 

Graduate Medical Education Safety-Net Consortiums are recognized by the President of the United States as THE Health and Human Services (HHS) gold standard community-based model for primary health care with integrated workforce development by June 30, 2027. 

OUR NICHE:  
World Class innovative and responsive primary health care through community-centric, incumbent and future workforce renewal. 

OUR CORE VALUES: 

Do the Wright thing 

Be privileged to serve 

Be an exceptional team player 

Strive for excellence 

Be driven for great results 

Spread positivity 

JOB SUMMARY 

This position is a new role in an emerging and dynamic Legal Department. This position is responsible for ensuring that non-clinical business operations and procedures comply with legal requirements and internal policies, is responsible for privacy investigations and managing all matters relating to insurance for the organizations. 

This position will perform a range of duties including evaluating all current and new non-clinical, non-finance related compliance regulations, auditing company processes, building the framework to ensure high integrity compliance, and leading training sessions for staff. The person in this role must engender the trust and confidence of all departments as the subject matter expert in compliance matters. He/she must also be an excellent communicator, have and continue to develop in-depth knowledge of the latest industry laws, rules and regulations. This position manages compliance, privacy matters, risk management and insurance programs for WCGME and TWCCH, including but not limited to HIPAA and 42 CFR Part 2 Compliance, Safe Event Reporting, and insurance management.  This position is also responsible for implementing and/or conducting all related staff and contractor trainings to promote our culture of accountability and high integrity in everything we do.  

JOB DUTIES and ESSENTIAL FUNCTIONS 

• Gain and maintain in-depth knowledge of both organizations and their respective activities in order to ensure adequate compliance (except in the areas of clinical and finance compliance), insurance and risk management oversight and resources as the organization evolves. 

• Ensure that the importance of ethical and legal conduct and applicable standards is communicated to all employees and that all employees receive periodic training in these matters. 

• Train and deliver educational programs for all staff on a yearly basis in all required areas of focus (such as HIPAA, HITECH, OSHA, etc.).   

• Own the metrics relating to HIPAA/privacy incidents, insurance compliance and training on the Legal Department Balanced Scorecard. 

• Ensure that any matter potentially requiring external reporting is communicated to the Director of Compliance and General Counsel. 

• Develop a reliable presence at and collaborate with clinic managers to increase awareness of the importance of the Compliance Program. 

• Spread the culture of transparently and courageously reporting all safe events and championing the PDSA process to continually enhance quality improvement and quality assurance efforts.  

• Create/implement policy and training programs for staff who access and enter information in MEDENT about proper documentation in patient charts. 

• Ensure medical malpractice insurance coverage and medical licenses are current for all providers. 

• Establish and maintain a mechanism to track access to protected health information (PHI) within the company, and as required by law, to allow qualified individuals to review reports on such activity; develop a random audit process and report template. 

• Maintain current knowledge of applicable federal and state laws, including but not limited to privacy laws, and monitor advancements in information privacy technologies to ensure organizational adaptation and compliance.  

• Collaborate with department leaders in solving problems involving legal or risk management implications. 

• Administer (investigate, resolve and report on) non-clinical incidents submitted through the SAFE Reporting system along with the organization-wide spread of learning from each report. 

• Collaborate with the Director of Compliance and all appropriate departments to ensure the regular and systematic reporting of SAFE events to Executive Management, the GMEC and Patient Safety & Quality Committees of the organization(s) and Boards of Directors. 

QUALIFICATIONS 

• Minimum bachelor’s degree in an associated field from an accredited college or university 

• HIPAA Privacy Certification preferred  

• Minimum 3 years compliance experience preferred 

• Solutions-oriented  

• Action-oriented 

• Self-directed 

• Experience in developing and implementing Compliance policies and education 

• Strong leadership capabilities with demonstrated ability to motivate staff toward change 

• Excellent skills in problem-solving and improvement, leading and coaching others, verbal and written communication 

• Proficient in Word, Excel, PowerPoint and the Google platform 

• Must be a team player who is responsible, reliable, task oriented and punctual 

• Must be able to perform effectively in a fast paced environment with many changing priorities 

• Must be professional and customer service oriented to deliver excellence 

• Ability to work independently  

• Have professional written and verbal communication and interpersonal skills 

• Willingness to work a flexible schedule 

• Some regional travel required; infrequent national travel possible 

PACE CARD Metrics 

• Achieve HIPAA Privacy Officer Certification (if not already achieved) 

• Develop and implement an annual Strategic Plan to continually assess and educate staff about patient privacy rights 

• Develop and maintain a mechanism to randomly audit and track access to protected health information (PHI) within the organizations and, as required by law, to allow qualified individuals to review reports on such activity; develop and implement a reporting framework. 

• Present HIPAA incident reporting to staff quarterly and submit official report of any HIPAA Breaches to OCR annually or as otherwise required 

• Develop the process and procedures to stack related PDSAs and SAFE events for reporting purposes; work with IT Department to automate and integrate with current systems; track on on-going basis and feed data to Balanced Score Card as well as GME Quarterly and Annual Reports 

• Meet quarterly with risk management parallels at affiliated clinical learning environments to ensure that resident-initiated or resident-driven PDSAs and safe events, and clinical staff-initiated and driven PDSAs and Safe events, are followed through and reported appropriately, and learning shared among and between all organizations and departments and programs